Dr Robert Wagner was a featured lecturer on “Stem Cell & Platelet Injections: Can They Help Heal Musculoskeletal Injuries?” at the Annual Sports Medicine Symposium at INOVA Mount Vernon Hospital (June 14, 2013).
Members of the National Athletic Trainers’ Association (NATA) attended along with area athletic trainers, physical therapists and sports medicine-oriented healthcare providers, Dr. Wagner discussed how stem cells and platelets promote better healing of injured tissues, what types of injuries can be effectively treated with stem cell and platelet injections, and outlined which patients are good and bad candidates for Regenerative Medicine techniques. These techniques are performed at Stem Cell Arts (www.stemcellarts.com) in Fairfax, Virginia by Mayo Friedlis, MD, Robert Wagner, MD and Rodney Dade, MD.
Other speakers at the conference included: Seminar 2013 Faculty-Annual Sports Medicine Symposium Program Director, Sameer Nagda, MD, Orthopedic Surgeon, Anderson Orthopaedic Clinic [Assistant Clinical Professor of Orthopaedic Surgery, Georgetown University School of Medicine; Team Physician Potomac Nationals Baseball Team]; George C. Branche, III, MD, Orthopedic Surgeon, Anderson Orthopaedic Clinic [Sports Medicine Consultant, Walter Reed Army, Medical Center; Clinical Preceptor, Physician Assistant Program, The George Washington University; Clinical Assistant Professor, Georgetown University School of Medicine; Consultant, ATP Tennis Tour]; J. Greg Bennett, PT, DSc, MS Adjunct Faculty, Orthopaedics and Sports Rehabilitation, Marymount University School of Physical Therapy; President, Excel Physical Therapy; Wiemi Douoguih, MD Orthopedic Surgeon, Director of Sports Medicine for MedStar Washington Hospital Center, Department of Orthopaedic Surgery; Medical Director – Washington Nationals Baseball Team (MLB); Cassie Gyuricza Root, MD, Orthopedic Surgeon/Hand Specialist Nirschl Orthopaedic Center; Stephen Saddler, MD, Orthopedic Surgeon, Anderson Orthopaedic Clinic; Assistant Clinical Professor of Orthopaedic Surgery, Georgetown University School of Medicine; Medical Director, Potomac Nationals Baseball Team; Robert H. Wagner, MD Pain Management Specialist Expert in PRP and Prolotherapy National Spine & Pain Center; Brent Wiesel, MD, Chief of Shoulder Surgery, Assistant Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Georgetown University School of Medicine
Our Dr. Robert Wagner was recently interviewed on WMAL Radio, where he discussed the causes, diagnosis and treatment of common overuse conditions such as tennis elbow, golfer’s elbow and other non-sports related scenarios that lead to painful joints. He also explains some of the common treatments that we use for these conditions, such as Platelet Rich Plasma (PRP) and Prolotherapy.
FAIRFAX, Va. (WUSA9) — For hardcore 30-year-old athletes to baby boomers, achy and worn out joints can literally be a pain.
Cateena Powers know about the pain, after years of athletic competition and training she developed arthritis in both knees.
She didn’t necessarily want to have her knees replaced. Especially after she found about a new stem cell therapy that can regenerate her current knees.
Powers says, “So I did the right knee first and it’s a series of injections.”
Video: Web Extra – Regenexx Procedure
“I would say I started to feel a difference maybe in about two days after that series of injections… two days! And then the next week I saw some definition in my knee. I thought, I can see my knee cap oh my gosh! So I said, i’m doing the left one.”
A new platelet-rich-therapy (PRP) called Regenexx is the latest in a number of PRP therapies that are growing in popularity.
These PRP therapies use the patient’s own stem cells to regenerate areas of the body that tend to wear down over time. This is used for a lot of conditions that used to require open surgery.
StemCell Arts in Fairfax is the only clinic in the Washington, D.C. metro area that offers this procedure.
Dr. Mayo Friedlis of StemCell Arts in Fairfax says, “We are treating a lot of rotator cuff problems that are actually rotator cup tears. We are treating epicondylitis or golfer’s elbow or tennis elbow, and we are treating hip arthritis, ankle achilles tendonitis, ankle sprains.”
“Anyplace that there’s a ligament or tendon injury is amenable to this,” adds Dr. Friedlis.
Physical fitness is a passion for 76 year old Norman Nicholson of Silver Spring. These days, he exercises for at least an hour everyday.
Nicholson says, “I figure skate, I ski, in the summer I bike, I hike.”
His fitness regimen is “Superman-like” for someone his age. But a few years ago, he stumbled upon his own version of kryptonite.
Nicholson says, “It was in 2010 when I started having problems with the knee.”
Due to the knee, he couldn’t do most exercises like he used to. After orthoscopic surgery and physical therapy he was still unable to do many of the things he wanted to. Nicholson saw Dr. Mayo Friedlis after learning about the Regenexx therapy.
Dr. Friedlis says, “Sometimes when we’re injured or when the body goes through a state of degeneration, we start developing arthritis or wear and tear as we age. The stem cells aren’t as plentiful.”
The hip bone marrow is full of plentiful, healthy stem cells. So the stem cells are extracted from the hip, so they can be applied to the injured area, where healthy stem cells are not as plentiful.
Before the stem cells are inserted into the injured section of the body, they are mixed into rich blood platelets. The red and white blood cells are separated from these platelets.
Dr. Friedlis says, “It turns out these red cells and white cells actually inhibit the platelets from doing thier thing.”
Once the platelets and stem cells are mixed and carefully injected into the body, amazing things can happen.
Dr. Friedlis says, “Those bone marrow cells will turn into cartilage cells, into ligament cells, tendon cells, wherever the are of injury is the stem cells are smart enough to figure out what they have to create.”
In Norman Nicholson’s case, he got some much needed cartilage. His knee has regenerated and it feels like he’s many years younger.
Nicholson says, “Last fall we did the stem cell treatments, and this February I was up in upstate New York. And for 4 days in a row I’ve spent an hour, hour and a half cross country skiing with no trouble at all… so i’m sold.”
This experimental procedure is not covered by insurance but it is covered by some flex spending plans.
All of the Regenexx procedures performed in the US are same-day procedures that comply with “CFR21 part1271“, requiring stem cells to be used on the same day that they are extracted.
Costs for this treatment can run between $4,000 to $6,000 depending on the patient. Some patients may benefit from cheaper, older PRP therapies that start around $1,200.
Here is the complete list of conditions this therapy treats:
Non-healing bony fracture
Bulging (non herniated) lumbar (lower back) disc
Avascular Necrosis of the shoulder, hip, knee, or ankle
Osteoarthritis of the knee, hip, or ankle
Partial tear of the rotator cuff
Meniscus tear or ACL, MCL tears
Knee, hip, and ankle pain
Limited range of motion, stiffness, swelling, and tenderness
Jim Bradley understands the season-on-the-brink desperation that, according to Fox Sports, sent Peyton Manning and his ailing neck to Europe this summer, seeking the experimental promise of stem cells. For the past two decades as the Steelers orthopedist, Bradley has listened to injured athletes beg him to be creative in getting them back onto the field. “In the last year, I’ve seen half a dozen guys go to South Korea, Japan, Germany, even Russia for stem cell procedures,” says Bradley, a past president of the NFL Physician’s Society. “And there’s going to be plenty more.”
ABC News, Stem Cells: Alternative to Knee Replacement?
By LIZ NEPORENT, ABC Medical Unit
Last year, Patricia Beals was told she’d need a double knee replacement to repair her severely arthritic knees or she’d probably spend the rest of her life in a wheelchair.
Hoping to avoid surgery, Beals, 72, opted instead for an experimental treatment that involved harvesting bone marrow stem cells from her hip, concentrating the cells in a centrifuge and injecting them back into her damaged joints.
“Almost from the moment I got up from the table, I was able to throw away my cane,” Beals says. “Now I’m biking and hiking like a 30-year-old.”
A handful of doctors around the country are administering treatments like the one Beals received to stop or even reverse the ravages of osteoarthritis. Stem cells are the only cells in the body able to morph into other types of specialized cells. When the patient’s own stem cells are injected into a damaged joint, they appear to transform into chondrocytes, the cells that go on to produce fresh cartilage. They also seem to amplify the body’s own natural repair efforts by accelerating healing, reducing inflammation, and preventing scarring and loss of function.
Christopher J. Centeno, M.D., the rehab medicine specialist who performed Beals’ procedure, says the results he sees from stem cell therapy are remarkable. Of the more-than-200 patients his Bloomfield, Colo., clinic treated over a two-year period, he says, “two thirds of them reported greater than 50 percent relief and about 40 percent reported more than 75 percent relief one to two years afterward.”
According to Centeno, knees respond better to the treatment than hips. Only eight percent of his knee patients opted for a total knee replacement two years after receiving a stem cell injection. The complete results from his clinical observations will be published in a major orthopedic journal later this year.
The Pros and Cons
The biggest advantage stem cell injections seem to offer over more invasive arthritis remedies is a quicker, easier recovery. The procedure is done on an outpatient basis and the majority of patients are up and moving within 24 hours. Most wear a brace for several weeks but still can get around. Many are even able to do some gentle stationary cycling by the end of the first week.
There are also fewer complications. A friend who had knee replacement surgery the same day Beals had her treatment developed life-threatening blood clots and couldn’t walk for weeks afterwards. Six months out, she still hasn’t made a full recovery.
Most surgeries don’t go so awry, but still: Beals just returned from a week-long cycling trip where she covered 20 to 40 miles per day without so much as a tweak of pain.
As for risks, Centeno maintains they are virtually nonexistent.
“Because the stem cells come from your own body, there’s little chance of infection or rejection,” he says. Not all medical experts are quite so enthusiastic, however. Dr. Tom Einhorn, chairman of the department of orthopedic surgery at Boston University, conducts research with stem cells but does not use them to treat arthritic patients. He thinks the idea is interesting but the science is not there yet.
“We need to have animal studies and analyze what’s really happening under the microscope. Then, and only then, can you start doing this with patients,” he says.
The few studies completed to date have examined how stem cells heal traumatic injuries rather than degenerative conditions such as arthritis. Results have been promising but, as Einhorn points out, the required repair mechanisms in each circumstance are very different.
Another downside is cost: The injections aren’t approved by the FDA, which means they aren’t covered by insurance. At $4,000 a pop — all out of pocket — they certainly aren’t cheap, and many patients require more than one shot.
Ironically, one thing driving up the price is FDA involvement. Two years ago, the agency stepped in and stopped physicians from intensifying stem cells in the lab for several days before putting them back into the patient. This means all procedures must be done on the same day, no stem cells may be preserved and many of the more expensive aspects of the treatment must be repeated each time.
Centeno says same day treatments often aren’t as effective, either.
But despite the sky-high price tag and lack of evidence, patients like Beals believe the treatment is nothing short of a miracle. She advises anyone who is a candidate for joint replacement to consider stem cells first.
“Open your mind up and step into it,” she says. “Do it. It’s so effective. It’s the future and it works.”
MINNEAPOLIS – On December 10, 2011, Portland guard Brandon Roy announced his retirement. He was 27 years old at the time, at the end of just his fifth year in the league. He’d been the NBA Rookie of the Year in 2007 and was a three-time All-Star.
Yet in the face of chronic knee problems, none of that mattered.
Roy retired due to persistent issues in both of his knees. He’d undergone six knee operations, and there was no longer any cartilage remaining in the joints. Trail Blazers team doctors warned him that he should not continue playing and that to do so would have devastating long-term effects.
Not even a year later, and he’s announced his comeback. Many teams have expressed interest in signing him, including the Timberwolves.
That’s quite the turnaround for a player who was warned that to play basketball any longer might spell difficulties walking later in his life. It’s the kind of story where one wonders what detail is missing; the turnaround is too drastic. And in that brief narrative, something was missing: platelet-rich plasma (PRP) therapy.
PRP therapy is a process by which a small quantity of blood is extracted from a patient. The blood is then placed in a centrifuge and spun until it separates into its component parts. Doctors then remove the platelets and inject them back into the patient at the point of injury, peppering the surrounding area with injections for maximum efficacy. The growth factors in platelets are said to promote healing and tissue regeneration, speeding the healing process.
The therapy has been used for nearly a decade, but it’s received increased attention in recent years. There’s no medical consensus on it yet, and it’s still a procedure that’s largely relegated to athletes and patients with disposable income. It can cost between $500-$2,000, though prices do vary, and it’s rarely covered by insurance.
Dr. Bradley Nelson, a physician at the University of Minnesota School of Medicine, said that the most common use of PRP therapy is for chronic tendinopathy. That’s different from the case in Roy’s knees, where he’s lacking cartilage. Using PRP therapy cases like Roy’s, though, is becoming more widespread, but it doesn’t have the same healing effects as it does in treating tendinopathy, such as tennis elbow. Recent studies have begun to indicate that PRP can be effective in reducing the pain of arthritis, and using the therapy in such treatments is the newest trend in PRP.
“Some people are injecting (PRP) into the knee joint in patients that have early osteoarthritis, and they can feel better,” Nelson said. “It does not grow new cartilage. It does not reverse the course of cartilage damage. It just helps with the pain associated with arthritis.”
For a case like Roy’s, more experimental stem cell treatments might hold a better chance in actual healing. It’s unclear whether Roy has undergone any such stem cell treatments, but he has received PRP therapy in both his hamstring and his knees. In recent years, some of the biggest names in sports have been associated with the therapy, most notably Kobe Bryant. Bryant, who received the treatment in Germany during the summer of 2011, had been suffering from lingering problems with an arthritic joint in his right knee.
“It wasn’t long before the sports community figured out this stuff is really powerful,” said Dr. Mayo Friedlis of StemCell ARTS, a Washington, D.C.-area practice. “It’s much better than cortisone and much better than surgery in a lot of cases. So athletes wanted to maintain their careers of course jumped on it.”
Other well-known players have also acknowledged trying PRP therapy, and today, many professional sports teams’ training rooms contain a centrifuge. Hines Ward received a variation of it just weeks before Super Bowl XLIII, and Tiger Woods, Fred Couples, Alex Rodriguez, Tracy McGrady, Chris Canty and Cliff Lee are among other athletes who have tried it.
Right now, PRP therapy is still breaking into the mainstream, but it’s widely accepted in the medical community. In fact, the therapy is nothing new; Friedlis has been using it for about seven years, and it actually was first pioneered longer ago than that. Originally, Friedlis said, a form of PRP was used after open-heart surgery to help the sternum mend, and since then it’s been used intraoperatively, especially in plastic and orthopedic surgery.
“This is the tipping point,” Friedlis said. “You’re seeing it right in front of your eyes. Biologics like PRP and stem cells are going to the wave of the future for treating any musculoskeletal injury, because first of all, they tap right into the body and heal it. They’re not just treating pain; they actually heal it, and they’re doing it in a natural fashion, so the healing that you get is true healing.”
So far, there’s not a sufficiently large body of research on PRP therapy for it to be covered by insurance companies, but that’s not to say that doctors aren’t taking advantage of it. Friedlis said that it’s such a natural process – using the body to heal the body – that it doesn’t have many potential negative side effects, making it something with which doctors are more willing to experiment. Even Nelson, who’s more cautious about the therapy’s efficacy, said that research has not found negative side effects, which makes it a procedure with which it’s easier to experiment.
Although the research on the therapy is limited, it’s inconclusive, and Friedlis cautioned that many researchers have not yet standardized the proper ways to administer the therapy in their studies. For instance, some studies involve just one injection at the site of the tear, rather than several surrounding it, Friedlis said. Others use any of about 20 different types of equipment, making it difficult for the results to be universally applicable. Even physicians, Nelson said, administer the therapy in different ways, and the consensus is still out as to the precise best way to deliver the therapy over different instances and injuries.
One recent study published in the British Journal of Sports Medicine by Dr. Leon Creaney, a London-based doctor, found that PRP injections were no more effective than whole blood injections in treating tennis elbow after three months and that whole blood was more effective after six months. However, another study by Dr. Allan Mishra at Stanford University found PRP more effective than cortisone in treating tennis elbow.
Much of the research support for PRP therapy has been derived from studies in which the procedure worked on mice. In such studies, muscle contusions and lacerations were inflicted upon the mice, and the therapy accelerated healing. Looking at the differences in study results, the changes efficacy might lie in the injuries themselves. The lacerations and contusions were acute injuries, the type that cause the body to initiate a much for effective, quick healing response. Injuries that most athletes suffer, everything from professionals’ knee problems to a mild case of tennis elbow, are the result of overuse. Those kinds of injuries cause the body to react differently, perhaps reducing PRP’s ability to enhance healing, and Nelson said that PRP’s efficacy in acute injuries is more agreed-upon than its effects in other circumstances.
That research, however, pales in comparison to the success stories and athletes who swear by PRP, and it’s too early in the process of learning about the therapy to allow such studies to take away from its possible impacts. In spite of its only recent popularity, or perhaps because of it, PRP is becoming more and more prevalent among athletes, and the procedure is fully acceptable in American professional sports.
There are few roadblocks to the procedure for athletes – it’s perfectly legal, and they have the financial resources to try it – and the only questions that remain are about its long-term efficacy. Many players who’ve undergone the treatment have improved; only a minority has not. Whether that improvement is a result of true healing or just pain reduction can depend on the injuries themselves and even on doctors’ opinions.
So far, there have been few downsides to trying the procedure. It hasn’t harmed an athlete’s performance, nor has it worked as an illegal performance enhancer. It’s simply a means of healing and pain relief, so teams whose players want to experiment with it shouldn’t take issue. The bigger questions come with athletes like Roy, whose problems were once so crippling that they were forced to retire. Can PRP therapy, especially in Roy’s case, where it might only provide pain relief, really cause such a turnaround? Or is a more experimental stem cell procedure necessary? There’s no way to prove Roy’s recovery empirically, and as a works out and meets with teams in the coming days, it’ll be up to them to judge.
StemCell ARTS is an Affiliate of National Spine and Pain Centers
If the regenerative treatment options offered by StemCell ARTS are not right for you, National Spine and Pain Centers provide more traditional treatments for spine and joint conditions.
Members of the National Athletic Trainers’ Association (NATA) attended along with area athletic trainers, physical therapists and sports medicine-oriented healthcare providers, Dr. Wagner discussed how stem cells and platelets promote better healing of injured tissues, what types of injuries can be effectively treated with stem cell and platelet injections, and outlined which patients are good and bad candidates for Regenerative Medicine techniques. These techniques are performed at Stem Cell Arts (www.stemcellarts.com) in Fairfax, Virginia by Mayo Friedlis, MD, Robert Wagner, MD and Rodney Dade, MD.
