Regenerative Medicine – Stem Cells
Treatment paradigm for regenerative medicine was the introduction of stem cells. Stem cells are biological cells found in multicellular organisms (like humans and other mammals) which can differentiate into other types of cells and/or may divide into more of the same type of cells. Adult stem cells are found in various tissues in the body, and they act as a repair system for the body with the goal of replenishing tissues. For example, stem cells lie in the bone marrow near the end of the bones toward the joint. Microtrauma may occur which stimulates the activation of stem cells which ultimately repair and rejuvenate the joint and thus limiting damage and degeneration. When a mismatch occurs between breakdown and repair, then the patient becomes prone to joint damage including osteoarthritis, bone infarcts (bone death), instability, asymmetry, pain, and dysfunction. Stem cells are present in multiple areas of the body, but the three most common are bone marrow, adipose tissue (fat cells), and blood.
The most common site for the harvesting of adult stem cells would be bone marrow. This procedure involves using a large bore needle to drill down in the bone primarily in the iliac crest or femur and withdrawing about ten cc’s of marrow at six different sites for a total of 60 cc’s of solution. The marrow is then centrifuged to obtain the stem cells. They are then injected into the target tissue similar to the way that PRP is done. The utility and indications for stem cells are similar to those treatments in the PRP and Prolotherapy sections which include joints, ligaments, tendons, muscles, nerve, skin, sexual organs, breasts, hair, and discs. There are also processes where the eyes, lungs heart, liver, spinal, cord, and brain may be treated with these cells. Stem cells are also commonly used in the treatment of certain cancers including leukemia and multiple myeloma. Before treatment, blood work is typically completed including a complete blood count with differential, calcium, phosphorus, alkaline phosphatase, magnesium, N-terminal telopeptide (NTX), vitamin K, and vitamin D levels. These laboratory studies evaluate for diseases of bone including leukemia, multiple myeloma, Paget’s disease, and osteoporosis. If there is evidence of cancer, deficiency, or osteopenia/osteoporosis, then the patient may be best treated by amniotic cells. This treatment will be further discussed below.
Stem cells are desirable as a treatment option as they may have a very potent effect in stimulating the healing response for the targeted tissue. Typical need is for 1-2 procedures that may be separated by months to years. Due to the time involved in the harvesting and injection (typically a 2-6 hours), these interventions are the most expensive of the regenerative procedures. There are protocols where prolotherapy injections and PRP injections are done on different days before the stem cell procedure to prime the joint for treatment. There are other protocols where prolotherapy and PRP are performed on the same day as the stem cells to augment the procedure. Stem cells tend to diminish as we age and they tend to do so more consistently in women than in men. Certain actions by the patient can improve the density of stem cells: fasting or intermittent fasting; ingestion of blueberries, green tea, pomegranates, goji berries, and spirulina; and bouts of acute exercise.
Stem cells are advantageous due to multiple reparative mechanisms. They change the environment of the joint from catabolic (breaking down tissue) to anabolic (building tissue). They encourage the release of growth factors and cytokines that result in the recruitment of other cells (paracrine effect) that help with tissue repair and restoration. Stem cells also support tissue remodeling over scar formation. The cells also secrete chemicals that alter the immune response and limit destruction of the joint by macrophages. This also serves to inhibit apoptosis or cell death. This allows the cells to survive longer and exert their positive effects on the target area. The beauty of stem cells in the musculoskeletal realm is that they may differentiate into bone, cartilage, tendon, and ligament tissue. For those patients that would not be considered candidates for bone marrow harvest due to cancer or osteoporosis, then alternative cells from amniotic fluid or umbilical cord membrane may be used. These substances may be injected into body areas and tissues similar to prolotherapy, PRP, and stem cells. They provide growth factors and other materials to help improve healing.
Contrary to their purported claims, these products contain no stem cells and when studied showed only dead cells. Much of this evaluation and laboratory investigation was performed by Dr. Chris Centeno who has pioneered much of the work and study on regenerative medicine techniques. These products are often pushed by chiropractors, naturopaths, and acupuncturists as stem cell-based procedures. These claims are misleading and fraudulent due to the aforementioned research. Often, these interventions are performed without imaging guidance which further limits the efficacy and benefit of the procedure. While these procedures may be helpful in the right circumstance and for the proper patient, consumers need to understand that all treatments are not the same. You also need to understand the training and competency of the physician in providing the most beneficial and cost-effective intervention. The take-home message for patients is to do your homework and fully vet your provider and clinic. Ask appropriate questions and if you have concerns, then consider a second opinion.