In August of 2012 I wrote about a 35 y.o. female who was our first stem cell orthopedic injection patient (see entry "Case Report #1 - T.M."). She has continued to do extremely well after her treatment and is now over one year out from the procedure. She continues to exercise in a manner that she could not prior to her stem cell therapy, including sports, hiking, and P-90-X. She denies pain and swelling in her right knee, and reports discomfort only in her left knee which has not had a stem cell injection.
On March 7, 2013 she underwent a repeat MRI of her right knee which was then compared to a prior MRI obtained on December 8, 2011.
In the time between the studies, her only treatment was the stem cell injection into the right knee joint which was done in February of 2012. Prior to the cell therapy, this patient's pain was most prominent in the inside aspect of the knee near her knee cap, which coincides with the anterior medial meniscus.
Important excerpts of the recent radiology report read as follows:
"Comparison is made to a prior study of the right knee dated 12/8/2011."
"An improved appearance of the marrow of the distal femur and tibia is noted when compared to the prior study.
Postoperative repair of the anterior horn of the medial meniscus has occurred since the prior exam."
The radiologist did not know that this patient had stem cell therapy, but obviously could detect changes that showed improvement in her primary orthopedic issue. We are very pleased to share these MRI findings and the fact that the radiologist saw evidence of meniscal repair.
Tuesday, April 2, 2013
Thursday, March 21, 2013
The Basics - What Exactly Is A Stem Cell?
A very common question happens to be one that goes back to the basics - what is a stem cell?
Stem cells are essentially building blocks that are found in all multicellular organisms. These cells can divide (through a process called mitosis), self renew, and differentiate into many different cell types.
Again, the classic definition of a stem cell requires that it possess the following properties:
In general, there are two broad types of stem cells: embryonic, which are isolated from blastocysts (a product of early gestation that leads to the development of the embryo), and adult stem cells, found in various tissues throughout the body. In the developing embryo, stem cells can differentiate into all specialized cells (these are called pluripotent cells) and also maintain the normal turnover of regenerative organs/tissues, such as blood, skin, or intestinal tissues. In adults, stem cells serve as the repair system for the body, replenishing adult tissues after injury or through the normal process of aging. Adult stem cells are multipotent, meaning they can differentiate into many cell types, but not all.
There are three readily-accessible sources of autologous (meaning from one's own body) adult stem cells in humans:
1. Bone marrow - requires extraction by drilling into bone (typically the iliac crest)
2. Adipose tissue (fat) - requires extraction by liposuction
3. Blood - requires extraction through the process of pheresis, wherein blood is drawn from the donor, passed through a machine that extracts the stem cells, then returns other portions of the blood back to the donor
Stem cells can also be found in umbilical cord blood just after birth.
Autologous harvesting involves the least risk when working with stem cells, as the cells are obtained from the patient's own body. Thus, there is no chance of an auto-immune reaction or tissue rejection. This also eliminates the risk of acquring an infection from another person.
Stem cells are essentially building blocks that are found in all multicellular organisms. These cells can divide (through a process called mitosis), self renew, and differentiate into many different cell types.
Again, the classic definition of a stem cell requires that it possess the following properties:
- Self-renewal: the ability to go through continued cycles of cell division while maintaining the undifferentiated state.
- Potency: the ability to differentiate into specialized cell types.
In general, there are two broad types of stem cells: embryonic, which are isolated from blastocysts (a product of early gestation that leads to the development of the embryo), and adult stem cells, found in various tissues throughout the body. In the developing embryo, stem cells can differentiate into all specialized cells (these are called pluripotent cells) and also maintain the normal turnover of regenerative organs/tissues, such as blood, skin, or intestinal tissues. In adults, stem cells serve as the repair system for the body, replenishing adult tissues after injury or through the normal process of aging. Adult stem cells are multipotent, meaning they can differentiate into many cell types, but not all.
There are three readily-accessible sources of autologous (meaning from one's own body) adult stem cells in humans:
1. Bone marrow - requires extraction by drilling into bone (typically the iliac crest)
2. Adipose tissue (fat) - requires extraction by liposuction
3. Blood - requires extraction through the process of pheresis, wherein blood is drawn from the donor, passed through a machine that extracts the stem cells, then returns other portions of the blood back to the donor
Stem cells can also be found in umbilical cord blood just after birth.
Autologous harvesting involves the least risk when working with stem cells, as the cells are obtained from the patient's own body. Thus, there is no chance of an auto-immune reaction or tissue rejection. This also eliminates the risk of acquring an infection from another person.
Thursday, February 14, 2013
Stem Cells and Heart Function
On November 6, 2012, at the American Heart Association Scientific Sessions meeting, Drs. Bolli (from the University of Louisville) and Anversa (from Brigham and Women's Hospital in Boston) presented updated data from their SCIPIO trial (Stem Cell Infusion in Patients with Ischemic CardiomyOpathy). This trial was a randomized open-label trial using cardiac stem cells in patients with heart failure after a heart attack, or myocardial infarction. The data they presented was the follow-up after 2 years.
The trial followed 33 patients who suffered a heart attack with measurable damage to the cardiac muscle. The patients all had a decreased LVEF (left ventricular ejection fraction), a standard measure of the heart's function measuring the blood ejected from the left ventricle during contraction of the heart muscle. In the study, the patients' LVEF had to be equal to or under 40%, with a normal LVEF being 50% or more. The trial involved harvesting patients' stem cells from their hearts during coronary artery bypass surgery and then multiplying these cells in the research team's lab. When approximately 1 million cells had been produced, the stem cells were then reintroduced into the region of the heart that had been scarred as a result of the heart attack.
Of the 33 patients, 20 actually received the stem cell therapy while the other 13 were in the control group receiving no stem cells. The researchers report that the 20 patients receiving stem cell therapy had marked improvement in cardiac function. Four months after the stem cell infusion, these pateints' average LVEF rose from 29% to 36%. At the one year mark, LVEF increased by 8.1%, while at the 2 year mark by 12.9%. The 13 control patients showed no improvement, on average.
Additionally, nine of the patients who received stem cells underwent MRI's and showed marked reduction in the size of the heart muscle scarring and resultant increase in viable muscle tissue. On average, the infarct size was 33.9 grams prior to treatment and 18.2 grams at the 2 year mark. The viable left ventricle tissue rose from 146.3 to 164.2 grams.
One patient in particular had suffered from two heart attacks prior to the study. His LVEF went from 38% to 58% after stem cell therapy, with his heart now showing essentially no ill effects from the prior myocardial infarctions.
The investigators plan to continue following these patients for two more years, and hopefully expand their resaerch with further funding.
The trial followed 33 patients who suffered a heart attack with measurable damage to the cardiac muscle. The patients all had a decreased LVEF (left ventricular ejection fraction), a standard measure of the heart's function measuring the blood ejected from the left ventricle during contraction of the heart muscle. In the study, the patients' LVEF had to be equal to or under 40%, with a normal LVEF being 50% or more. The trial involved harvesting patients' stem cells from their hearts during coronary artery bypass surgery and then multiplying these cells in the research team's lab. When approximately 1 million cells had been produced, the stem cells were then reintroduced into the region of the heart that had been scarred as a result of the heart attack.
Of the 33 patients, 20 actually received the stem cell therapy while the other 13 were in the control group receiving no stem cells. The researchers report that the 20 patients receiving stem cell therapy had marked improvement in cardiac function. Four months after the stem cell infusion, these pateints' average LVEF rose from 29% to 36%. At the one year mark, LVEF increased by 8.1%, while at the 2 year mark by 12.9%. The 13 control patients showed no improvement, on average.
Additionally, nine of the patients who received stem cells underwent MRI's and showed marked reduction in the size of the heart muscle scarring and resultant increase in viable muscle tissue. On average, the infarct size was 33.9 grams prior to treatment and 18.2 grams at the 2 year mark. The viable left ventricle tissue rose from 146.3 to 164.2 grams.
One patient in particular had suffered from two heart attacks prior to the study. His LVEF went from 38% to 58% after stem cell therapy, with his heart now showing essentially no ill effects from the prior myocardial infarctions.
The investigators plan to continue following these patients for two more years, and hopefully expand their resaerch with further funding.
Friday, December 7, 2012
Stem Cells to Treat Alzheimer's Disease
A recent article in the December, 2012 issue of Stem Cells by Chen and Burton-Jones describes potential stem cell treatments for Alzheimer's disease (AD), as well as the use of stem cells to model and investigate the disease. They offer encouraging information on how stem cells might play a part in future therapy, based on a number of past and ongoing research studies.
Alzheimer's disease is the most common type of age-related dementia that affects over 5 million people in the U.S., with projections that 115 million people worldwide may develop dementia by the year 2050. Current treatment modalities provide no long-term benefits, even after extensive research for many years.
Stem cell treatment options have been under investigation using animal studies, with some enlightening findings so far. For the majority of diseases and disorders that are treated with stem cells, the therapy is aimed at replacing missing or degenerative cells with new ones. In the case of AD, that type of treatment would not be likely to produce a benefit, as a number of neuronal systems and neurotransmitter phenotypes can be affected and cell replacement would not be viable. Too many types of nerves are involved, along with the complex systems of connectivity, much of which develops in utero. Therefore, cell replacement would not seem to offer benefit with such a diffuse set of problems that are encountered in AD.
So how could stem cells be of benefit? Well, the benefits seem to come through indirect means. One of the problems found in AD is a loss of synapses. This loss seems to correlate most tightly with the dementia process. The number of synapses and their relative strength appears to be closely regulated by a select group of neurotrophins, groups of secreted proteins that induce the development, function, and survival of neurons. These are essentially growth factors for our nervous system. Stem cells can induce high levels of these growth hormones, including brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF). In this way, stem cell therapy might allow for delivery of these proteins to the disease-affected areas of the brain and thus possibly increasing neuronal survival.
Another known factor in AD is chronic inflammation. Stem cells can have anti-inflammatory properties, as certain stem cell populations have been shown to induce the expression of anti-inflammatory factors, specifically interleukin-10 and prostaglandin E2. There are mice studies that have shown improved cognition and improved pathology due to apparent attenuation of the inflammatory process after treatment with stem cells. However, it is not known how this will translate to human patients, if at all, as prior clinical trials with anti-inflammatory drugs have shown no benefit in patients with AD.
Another potential way that stem cells could provide some benefit is by delivering therapeutic proteins to the damaged areas in the brain, as prior studies have shown the ability of stem cells to migrate throughout the brain and focus on regions damaged by injury and/or inflammation. What is not yet known is how much of an effect the underlying pathology plays on this response, as the severity of the disease might influence the likelihood of success, along with unknowns surrounding the lifespan of engrafted cells, the patient's immune response, and even the source of the cells and proteins.
As the excitement grows related to the possibilities, caution must be encouraged as more studies need to be undertaken. Difficulties exist in researching treatment options for AD, as no long term human studies have taken place. Stem cells may prove quite useful in studying the AD process, as stem cell lines can be elicited that exhibit known AD-associated genes. This will allow for researchers to focus on the differences between the normal and pathogenic function of these genes.In this way, stem cells may hold the key to learning more about the disorder and to eventually treating it.
Alzheimer's disease is the most common type of age-related dementia that affects over 5 million people in the U.S., with projections that 115 million people worldwide may develop dementia by the year 2050. Current treatment modalities provide no long-term benefits, even after extensive research for many years.
Stem cell treatment options have been under investigation using animal studies, with some enlightening findings so far. For the majority of diseases and disorders that are treated with stem cells, the therapy is aimed at replacing missing or degenerative cells with new ones. In the case of AD, that type of treatment would not be likely to produce a benefit, as a number of neuronal systems and neurotransmitter phenotypes can be affected and cell replacement would not be viable. Too many types of nerves are involved, along with the complex systems of connectivity, much of which develops in utero. Therefore, cell replacement would not seem to offer benefit with such a diffuse set of problems that are encountered in AD.
So how could stem cells be of benefit? Well, the benefits seem to come through indirect means. One of the problems found in AD is a loss of synapses. This loss seems to correlate most tightly with the dementia process. The number of synapses and their relative strength appears to be closely regulated by a select group of neurotrophins, groups of secreted proteins that induce the development, function, and survival of neurons. These are essentially growth factors for our nervous system. Stem cells can induce high levels of these growth hormones, including brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF). In this way, stem cell therapy might allow for delivery of these proteins to the disease-affected areas of the brain and thus possibly increasing neuronal survival.
Another known factor in AD is chronic inflammation. Stem cells can have anti-inflammatory properties, as certain stem cell populations have been shown to induce the expression of anti-inflammatory factors, specifically interleukin-10 and prostaglandin E2. There are mice studies that have shown improved cognition and improved pathology due to apparent attenuation of the inflammatory process after treatment with stem cells. However, it is not known how this will translate to human patients, if at all, as prior clinical trials with anti-inflammatory drugs have shown no benefit in patients with AD.
Another potential way that stem cells could provide some benefit is by delivering therapeutic proteins to the damaged areas in the brain, as prior studies have shown the ability of stem cells to migrate throughout the brain and focus on regions damaged by injury and/or inflammation. What is not yet known is how much of an effect the underlying pathology plays on this response, as the severity of the disease might influence the likelihood of success, along with unknowns surrounding the lifespan of engrafted cells, the patient's immune response, and even the source of the cells and proteins.
As the excitement grows related to the possibilities, caution must be encouraged as more studies need to be undertaken. Difficulties exist in researching treatment options for AD, as no long term human studies have taken place. Stem cells may prove quite useful in studying the AD process, as stem cell lines can be elicited that exhibit known AD-associated genes. This will allow for researchers to focus on the differences between the normal and pathogenic function of these genes.In this way, stem cells may hold the key to learning more about the disorder and to eventually treating it.
Thursday, November 29, 2012
Stem Cells / PRP in Tendon Injuries
Tendons are highly prone to injury due to their inherent design and function. Relative to other structures, tendons are hypovascular, meaning they have a poor blood supply. Tendons typically have a cross-sectional area that is significantly less than the in-line muscle, and therefore, considerable stress is placed on the tendon, especially during exercise. The primary function of a tendon is to transmit the force of muscular contraction to the skeletal system, thereby generating movement. It is this mechanical force that can lead to excessive stress that causes injury.
Due to these factors, tendons are frequently injured, and the natural healing response is slow and inefficient. The 1999 publication Musculoskeletal Conditions in the United States by Praemer, Furner, & Rice, estimates that $30 billion is spent in the U.S. each year on musculoskeletal injuries, and approximately 45% of these are tendon and/or ligament injuries. In an effort to show just how common tendon injuries are, an article by Sher, et. al., in 1995 entitled "Abnormal findings on magnetic resonance images of asymptomatic shoulders" found an overall incidence of shoulder rotator cuff tears to be 34% across all age groups, even though these patients all had no pain and exhibited normal functional activity. The percentage was smaller in younger patients and increased with advancing age, as 54% of the patients over the age of 60 had cuff tears.
Surgical repair of tendon injuries has become increasingly more common, although such repairs are often unsuccessful. Bishop, et. al., published a study in 2006 called "Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study" in which they conclude that while small cuff tears have reasonable surgical outcomes, large tears show failure rates up to 75%. Thus, traditional surgey is no guarantee of restored function and elimination of pain.
One factor in the difficult recovery from a tendon injury is that scarring can occur during the healing process. The area of the tendon that scars is never able to be as fully functional as it once was, and is even more prone to re-injury. This is an important advantage in treating this type of injury with stem cells, as the stem cells can be used by the body to grow new tendon instead of scar tissue. This then leads to a functionally superior outcome.
We believe that dual treatment with stem cells (for the reason listed above) and platelet rich plasma (PRP) offers the best possible solution. The stem cells will be used as the body needs them to regenerate tendon, while the PRP gives concentrated growth factors and platelets directly to the site of injury to promote healing. This tecnique is not only useful for rotator cuff treatment, but can be used for any tendon injury (Achilles, "tennis elbow", other shoulder tendons, etc.).
Due to these factors, tendons are frequently injured, and the natural healing response is slow and inefficient. The 1999 publication Musculoskeletal Conditions in the United States by Praemer, Furner, & Rice, estimates that $30 billion is spent in the U.S. each year on musculoskeletal injuries, and approximately 45% of these are tendon and/or ligament injuries. In an effort to show just how common tendon injuries are, an article by Sher, et. al., in 1995 entitled "Abnormal findings on magnetic resonance images of asymptomatic shoulders" found an overall incidence of shoulder rotator cuff tears to be 34% across all age groups, even though these patients all had no pain and exhibited normal functional activity. The percentage was smaller in younger patients and increased with advancing age, as 54% of the patients over the age of 60 had cuff tears.
Surgical repair of tendon injuries has become increasingly more common, although such repairs are often unsuccessful. Bishop, et. al., published a study in 2006 called "Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study" in which they conclude that while small cuff tears have reasonable surgical outcomes, large tears show failure rates up to 75%. Thus, traditional surgey is no guarantee of restored function and elimination of pain.
One factor in the difficult recovery from a tendon injury is that scarring can occur during the healing process. The area of the tendon that scars is never able to be as fully functional as it once was, and is even more prone to re-injury. This is an important advantage in treating this type of injury with stem cells, as the stem cells can be used by the body to grow new tendon instead of scar tissue. This then leads to a functionally superior outcome.
We believe that dual treatment with stem cells (for the reason listed above) and platelet rich plasma (PRP) offers the best possible solution. The stem cells will be used as the body needs them to regenerate tendon, while the PRP gives concentrated growth factors and platelets directly to the site of injury to promote healing. This tecnique is not only useful for rotator cuff treatment, but can be used for any tendon injury (Achilles, "tennis elbow", other shoulder tendons, etc.).
Tuesday, October 9, 2012
Nobel prize winners for stem cell work
Professor John Gurdon of the UK and Shinya Yamanaka of Japan were recently awarded a shared Nobel prize for medicine or physiology based on their pioneering work in the area of stem cells. They both did influential research in changing adult cells into stem cells.
In 1962, Gurdon first showed that genetic information inside of a cell can be used to create an entirely new organism. He took genetic information from an intestinal cell of a frog and placed this material inside a frog egg. The clone then proceeded to develop into a normal tadpole. This technique was the foundation of the work involving Dolly the sheep, the very first cloned mammal.
Yamanaka used a different approach forty years later, finding a way to reset the genetic information. Instead of transferring the genetic material from one cell and implanting this inside an egg, he added genes to skin cells which then turned into stem cells.
The Nobel committee stated that their work "revolutionized our understanding of how cells and organisms develop," and that "these discoveries have also provided new tools for scientists around the world and led to remarkable progress in many areas of medicine."
The director of the Wellcome Trust, Sir Mark Walport, said that these men "have demonstrated conclusively that it is possible to turn back the clock on adult cells, to create all the specialised cell types in the body. Their work has created the field of regenerative medicine, which has the potential to transform the lives of patients with conditions such as Parkinson's, stroke, and diabetes."
Although research in this field has been going on for decades, we have only recently begun to use the knowledge clinically to treat patients. As more clinical trials and studies progress, the use of stem cells in medicine will surely grow. I am excited to see these advances occurring all the time.
In 1962, Gurdon first showed that genetic information inside of a cell can be used to create an entirely new organism. He took genetic information from an intestinal cell of a frog and placed this material inside a frog egg. The clone then proceeded to develop into a normal tadpole. This technique was the foundation of the work involving Dolly the sheep, the very first cloned mammal.
Yamanaka used a different approach forty years later, finding a way to reset the genetic information. Instead of transferring the genetic material from one cell and implanting this inside an egg, he added genes to skin cells which then turned into stem cells.
The Nobel committee stated that their work "revolutionized our understanding of how cells and organisms develop," and that "these discoveries have also provided new tools for scientists around the world and led to remarkable progress in many areas of medicine."
The director of the Wellcome Trust, Sir Mark Walport, said that these men "have demonstrated conclusively that it is possible to turn back the clock on adult cells, to create all the specialised cell types in the body. Their work has created the field of regenerative medicine, which has the potential to transform the lives of patients with conditions such as Parkinson's, stroke, and diabetes."
Although research in this field has been going on for decades, we have only recently begun to use the knowledge clinically to treat patients. As more clinical trials and studies progress, the use of stem cells in medicine will surely grow. I am excited to see these advances occurring all the time.
Thursday, August 23, 2012
Case Report #1
Case Report #1 - T.M.
Our first stem cell patient is a 35 year old female who presented with right knee pain and swelling. She weighed 143 pounds at 5'8" height. She first injured her knee at age 13 when she tore her anterior cruciate ligament (ACL) and damaged the meniscus while playing basketball. She continued to play for many months before having a knee scope with meniscal repair later that same year. The following year she underwent ACL reconstruction with another meniscal repair. Her knee did not improve much after that, and 6 years later she again had an ACL reconstruction and meniscal repair. The following year she had IT (iliotibial) band repair in an attempt to help stabilize her knee joint. Finally, 5 years after that (at age 28), she had a meniscectomy to remove the damaged meniscus.
Unfortunately, the end result of these many surgeries was that she had ongoing pain and inability to play sports and be active with her children. Using a pain scale of 0 (no pain) to 10 (unbearable pain), her usual pain was 3-4, and at its most severe was 7-8. Any activity involving repeated bending of the joint would worsen her symptoms, and she would often then experience days of swelling. She limited her activity so as to not cause pain, and would have to take anti-inflammatory medications and use ice packs when she was active. An MRI reported chondromalacia (a break-down of cartilage inside the joint) with evidence of meniscal damage. She was very reluctant to undergo any other orthopedic surgeries given the dismal results she had in the past, and instead wished to pursue a stem cell injection.
We helped to implement a pre-op plan involving her diet, addition of a variety of supplements, and cessation of tobacco smoking and alcohol use. She was very motivated and completely eliminated smoking and alcohol for months prior to surgery. She then underwent stem cell harvesting using manual liposuction, along with preparation of platelet-rich plasma (PRP) from her blood. Once her stem cells were isolated, we mixed the stem cells and PRP and injected this mixture into her right knee joint.
She experienced some discomfort for a day or two after the injection, but this pain was not any worse than her usual pain. Our post-op plan consisted of a continuation of her diet, along with continued abstinence form tobacco and alcohol. We also avoided anti-inflammatories after the procedure, as the inflammatory process helps the stem cells and PRP heal the damaged tissues. We started a physical therapy plan at that time as well. Initially this consisted of passive reistance exercises. She did these for two weeks, then advanced to mild weight bearing exercises (such as half-lunges and partial squats). As these exercises became easier over the following few weeks, we then advanced to full range of motion exercises, then on to weight lifting. She was able to do these with very minimal pain and less swelling than in the past. She now is able to play basketball again, ride a bicycle, take long hikes with her children, and even perform plyometric (ie., "jump training") exercises, all of which were out of the question just a few months ago! She is very happy with the results, and is a firm believer in stem cells!
Our first stem cell patient is a 35 year old female who presented with right knee pain and swelling. She weighed 143 pounds at 5'8" height. She first injured her knee at age 13 when she tore her anterior cruciate ligament (ACL) and damaged the meniscus while playing basketball. She continued to play for many months before having a knee scope with meniscal repair later that same year. The following year she underwent ACL reconstruction with another meniscal repair. Her knee did not improve much after that, and 6 years later she again had an ACL reconstruction and meniscal repair. The following year she had IT (iliotibial) band repair in an attempt to help stabilize her knee joint. Finally, 5 years after that (at age 28), she had a meniscectomy to remove the damaged meniscus.
Unfortunately, the end result of these many surgeries was that she had ongoing pain and inability to play sports and be active with her children. Using a pain scale of 0 (no pain) to 10 (unbearable pain), her usual pain was 3-4, and at its most severe was 7-8. Any activity involving repeated bending of the joint would worsen her symptoms, and she would often then experience days of swelling. She limited her activity so as to not cause pain, and would have to take anti-inflammatory medications and use ice packs when she was active. An MRI reported chondromalacia (a break-down of cartilage inside the joint) with evidence of meniscal damage. She was very reluctant to undergo any other orthopedic surgeries given the dismal results she had in the past, and instead wished to pursue a stem cell injection.
We helped to implement a pre-op plan involving her diet, addition of a variety of supplements, and cessation of tobacco smoking and alcohol use. She was very motivated and completely eliminated smoking and alcohol for months prior to surgery. She then underwent stem cell harvesting using manual liposuction, along with preparation of platelet-rich plasma (PRP) from her blood. Once her stem cells were isolated, we mixed the stem cells and PRP and injected this mixture into her right knee joint.
She experienced some discomfort for a day or two after the injection, but this pain was not any worse than her usual pain. Our post-op plan consisted of a continuation of her diet, along with continued abstinence form tobacco and alcohol. We also avoided anti-inflammatories after the procedure, as the inflammatory process helps the stem cells and PRP heal the damaged tissues. We started a physical therapy plan at that time as well. Initially this consisted of passive reistance exercises. She did these for two weeks, then advanced to mild weight bearing exercises (such as half-lunges and partial squats). As these exercises became easier over the following few weeks, we then advanced to full range of motion exercises, then on to weight lifting. She was able to do these with very minimal pain and less swelling than in the past. She now is able to play basketball again, ride a bicycle, take long hikes with her children, and even perform plyometric (ie., "jump training") exercises, all of which were out of the question just a few months ago! She is very happy with the results, and is a firm believer in stem cells!
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