Health feature: Regenerative therapies, part 2: The here and now
July 19, 2016
Editor's note: This is the second article in a series about regenerative therapies. The intention of this series is to inform medical consumers about current and future choices when looking at potentially undergoing a stem cell treatment and to provide a coherent explanation of what we know and are trying to understand about this new wave of medicine.
The growing field of regenerative medicine and biologics is one that researchers are spending countless hours trying to advance, and although there is still much to learn about the specific dynamics of stem cells and their interaction throughout the body, many are trying to use what is known to effectively treat patients today.
While there are many applications that clinicians and researchers agree are not yet ready to be used in treating patients, the known applications for stem cells are creating less invasive techniques in the field of orthopedics, in particular.
In 2009, Pittsburgh Steeler Hines Ward made a seemingly miraculous comeback after tearing the medial collateral ligament in his knee during the AFC Championship game to play in the Super Bowl two weeks later. Much of Ward's recovery in such a short amount of time was credited to a platelet rich plasma injection, with news outlets crediting the star's recovery to the new and groundbreaking stem cell treatment.
Professional athletes are superb biomechanical specimens who have spent hours, days and years of their lives reaching the pinnacle of training for a given skill, which often makes them ideal subjects to progress new advances in medicine. Their resiliency in this regard led to some of the first arthroscopies and anterior cruciate ligament repairs being done on this small group of individuals, and currently, elite athletes find themselves among the first to be receiving injections containing stem cells and other regenerative tissues to repair areas of injury or chronic pain.
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This isn't to say that these treatments don't work on other demographics of patients, but physicians applying such treatments often caution individuals that results aren't as cut and dry as the result Ward experienced, and there's no magic injection that will lead to instantaneous results.
Dr. Robert LaPrade, of The Steadman Clinic explained that while athletes often offer a good starting point to work from when applying new medical techniques, the ongoing research involving regenerative medicine makes it difficult at times to pinpoint what type of treatment a person outside of that group might respond to.
"We always have to advance based on how we treat our athletes, and they help us move forward and provide those treatments for others," he said. "But sometimes you might find out that it's not working as well, depending on the individual, and you have to customize it."
Using what we know
The customization piece of the puzzle is one that still poses questions to researchers, as the application of regenerative medicine has been promising, but the independent variables posed by different patients, their conditions and the stem cells themselves can sometimes lead to inconsistent results.
Dr. Scott Brandt explained that at his clinic, ThriveMD in Edwards, he tries to focus on using the current knowledge about the field to treat mostly soft-tissue problems caused by both injury and degeneration.
"You've got this giant research realm out there that's really trying to figure out what cells with what growth factors are going to create the best environment for cell growth, and in the clinical realm, we've taken what we have that's the best practice right now, what shows the most promise in the studies that have been done for regeneration of different tissues," he said.
Similarly, the use of biologics to treat a medley of ailments within orthopedics is one that many clinicians, like Brandt, feel have good research to support in a conservative setting for things such as osteoarthritis, muscle tears, tendon problems and ligament damage.
"If you look at where stem cells are being used, this orthopedic niche is probably the most profound as far as success rates and clinical trials that have actually demonstrated good use for it," he said.
The procedure involved in receiving a stem cell treatment typically comes in the form of a platelet rich plasma (PRP) injection, or a bone marrow aspirate concentrate (BMAC) injection, although there are a few other sources, such as fat, that are sometimes used, as well.
In Ward's case, he received a platelet rich plasma injection, which consists of blood that is centrifuged to a concentrate and then injected into the site of injury. This isn't a stem cell rich injection; platelet rich plasma is essentially a growth factor that contains tissues and other cytokines that act to facilitate healing in a given area.
While this can generate a response on its own, as it did with the Super Bowl champion, platelet rich plasma is often accompanied by a bone marrow aspirate concentrate injection, which contains a small dose of stem cells in the centrifuged formula to assist in providing beneficial results to the damaged area.
Bone marrow for the injections is taken from the iliac crest, which constitutes part of the pelvis, and offers a large, wide area for clinicians to take a sample of bone for the procedure. These aspirates are subject to strict regulation, with physicians unable to alter the samples or store them for future use.
And while physicians might look at some sort of an injection to avoid surgery, many are quick to point out that these regenerative techniques often work in combination with more invasive treatments. Dr. Thos Evans, of The Steadman Clinic, explained that potential patients should understand that one injection might not be the cure-all.
"Regenerative medicine therapies do not replace the need for surgery, but they are less invasive and present a lower risk option for many patients," he said. "These therapies provide the physician with another conservative treatment option, other than surgery, and in some cases, PRP and BMAC therapies are also used in conjunction with surgery to improve patient outcomes."
Patients should approach these treatments with similar preparation as they would for a major medical event, as individuals with better baseline health often see better results. Evans also explained that the rehabilitation process after receiving an injection may take time, and individual response varies on a case-by-case basis.
"Following a PRP or BMAC injection, our patients may note reduced pain and improved function shortly after the procedure or gradually over several months," he said. "Recovery also depends on the type and severity of injury, as well as the individual's response to the treatment. Each patient is unique, they may require just a one-time treatment, a series of injections or a biannual maintenance injection schedule."
Currently, regenerative injections are not covered by health insurance, although doctors see the progress being made and the benefits to patients as something that will expand access to more people.
The hope and the goal, however, is that by furthering the research to create a more compelling body of data and studies to back up the benefits of biologics, someday stem cell treatments will be standardized in their effectiveness and will be attainable for a range of individuals and conditions.