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!

PRP (Plasma Therapy)

Platelet Rich Plasma (PRP) is a treatment that can be used as a stand-alone therapy or in conjunction with stem cell therapy.  PRP is essentially a super-concentrated collection of platelets and growth factors in the plasma portion of your blood.  This autologous blood product is used to facilitate the healing process via the higher than normal concentration of platelets and through the release of a substantial amount of growth factors that then stimulate recovery in non-healing or slowly healing wounds/injuries.

Chronic injuries often occur in situations where the injured tissue has poor blood flow (such as tendon injuries and cartilage degeneration).  PRP causes a supra-physiologic release of a variety of growth factors that serve to promote the healing process.  Studies have shown that this occurs because these bioactive substances attract stem cells, macrophages, and osteoblasts to the affected area, thereby stimulating tissue regeneration and healing, along with the removal of necrotic tissue.  Platelets themselves are responsible for the development of new blood vessels and connective tissue.

PRP has been finding increased use in chronic tendon injuries, as these injuries are often very slow to heal.  Tendons are susceptible to injury due to mechanical issues related to the forceful stress on the tendon fibers, causing them to be more vulnerable than other tissues.  These injuries are then slow to heal due to general poor vascularity. In addition, tendons often heal through scarring, a process that adversely affects how well they function and increases the probability of re-injury in the future.  PRP can be used to help augment the natural healing process by promoting true healing (not scarring) and re-vascularization, and by speeding the healing process.  This treatment is increasingly used for lateral epicondylitis ("tennis elbow"), plantar fasciitis, and in chronic Achilles and patellar tendon injuries.  For more information, see studies by Mishra et al. in 2006 in the American Journal of Sports Medicine and by Edwards & Calandruccio in American Journal of Hand Surgery in 2003.

Plasma therapy has also shown to be helpful in non-healing skin wounds related to peripheral vascular disease, neurologic conditions, trauma, infection, etc.  A 2006 study by McAleer et al. [McAleer JP, Kaplan E, Persich G. Efficacy of concentrated autologous platelet-derived growth factors in chronic lower-extremity wounds. J Am Podiatr Med Assoc. 2006;96(6):482-8.] showed very promising results in healing wounds that had previously failed all other treatments.

In addition, PRP is used with stem cell therapy to promote an intense healing response.  The stem cells act as the "seeds", while the PRP serves as the "fertilizer".  The growth factors help the stem cells to differentiate into the proper cell lines, promote vascularization of the new tissue, and augment the inflammatory response for an overall faster recovery.

Why adipose-derived stem cells?

So why do we take stem cells from fat?

First, fat (or adipose tissue) contains stem cells that are capable of developing into a variety of cell types.  This is called multilineage differentiation capacity.  The stem cells can turn into bone, cartilage, cardiac muscle, skeletal muscle, nerve tissue, and even blood vessels. That ability makes these cells useful in a multitude of treatment scenarios, for many types of disease processes.  Specifically, these cells work for orthopedic injuries because they can help regenerate bone, cartilage, ligament, and/or tendon, while also helping to provide new vascular supply to the injured area.

Secondly, these cells are rather easily obtained, and in large numbers.The process of tumescent liposuction has minimal morbidity and is relatively benign for the patient.  The alternative is obtaining stem cells from bone marrow, a procedure that involves punching a hole through the bone, usually in the hip, and then extracting marrow from the inner space of the bone.  This can be quite uncomfortable, and requires a larger incision.

Lastly, fat seems to result in an overall larger number of viable stem cells than bone marrow.  This is important in that this higher cell count could result in more viable cells being used in the treatment area, with a potentially greater chance of a beneficial outcome.

(For those interested, the first two points are mentioned in a review article published in 2005 titled Multipotential differentiation of adipose-derived stem cells, by Strem, et. al.  The last point comes from independent research from a group in Florida that has studied stem cells from both fat and marrow.)

Because of these things, our first choice is to obtain cells from fat when possible, using bone marrow aspiration as a back-up plan.  And it is usually possible to get enough adipose tissue from patients in the general population, as we do not need a large amount.

The stem cells are isolated from the adipose tissue by tissue washing and enzymatic digestion, and separated from other cellular material via a centrifuge.  The preparation can take 1.5 to 2 hours, after the actual liposuction procedure that can take an hour or more. Thus, this is a same-day procedure, with minimal discomfort and essentially no down time.

Introduction

Hello, and welcome to the first installment of the Colorado Stem Cell Therapy blog!  My goal with this blog is to keep the general public up-to-date on the current advancements in stem cell research and treatments, and I will attempt to make the science easily understood by non-medical readers.  This first blog will be a rather general overview, not particularly detailed or too focused on one thing.

First, here is a little about me.  My background as a physician has taken a rather non-linear route since medical school.  My formal residency training was in the field of Anesthesiology, and I practiced in that field for many years.  I was proficient in all types of general anesthesia, spinal and epidural anesthesia, and conscious sedation.  I also performed regional anesthesia which involved a variety of nerve blocks and injections for pain control.  I subsequently studied the diagnosis and treatment for varicose and spider veins with my medical practice partner, Dr. William Schuh.  I learned to use a laser for certain surgical procedures for vein disease, and have been performing these over the past three years.  That development of laser surgery skills then led me to the practice of laser liposuction/liposculpture.  And that in turn has most recently allowed me to pursue the therapies involving isolation and use of stem cells.

The stem cell treatments that we will focus on in our practice involve the use of a patient’s own fat (or possibly bone marrow).  This is usually a one day procedure, over the course of a few hours.  There is no ethical dilemma such as the media has brought to the public’s attention in regard to the use of embryonic stem cells, nor is there a problem with rejection of the cells since they are the patient’s own tissue. 

In order to get the patient’s stem cells, it is first necessary to obtain fat.  This is done through a liposuction procedure performed in our office, with local anesthesia and some oral medications to help with anxiety and pain.  The recovery of the stem cells can be combined with a more traditional liposuction procedure as well, if so desired by the patient.  The fat then has to go through a rather rigorous processing procedure that includes enzymatic washing and cell isolation.  The stem cells that were dormant in the fat tissue are then ready to be used for a variety of clinical applications.

Stem cell therapy can be useful in treating the symptoms of a wide array of medical conditions.  Our practice is mostly focused on treatment of orthopedic injuries.  This can include sport-related injuries, arthritis, joint pain, and muscle/tendon/ligament pain.  Once the stem cells are isolated, they can be injected into the affected joint or tissue.  When the stem cells are in that environment, the patient’s body basically directs these cells to turn into different kinds of cells, such as cartilage, muscle, bone, etc.  The body will determine what is needed, and then the stem cells do their thing!

This kind of therapy doesn’t work for everyone, nor does it always work after just one treatment.  It can take time for the effect to become noticeable, and there are a variety of things that can influence the outcome.  Examples include smoking, alcohol consumption, diet, age, and activity level, just to name a few.  We will counsel individuals in these types of areas to best manage their problem/condition, and attempt to maximize the benefit. 

Again, this is just a quick overview of current advances in stem cell therapies.  Future blogs will cover current research topics, current clinical advances, and updates about our practice.  Feel free to comment or ask questions – I will do my best to address them all.