Joint Preservation Blog

February 12, 2009

Bone Marrow Nucleated Cell Concentrate (BMAC): Is it Concentrated Enough?

 

bmac machine

bmac machine

 

In 2005-2006 we mixed up BMAC in our cell biology lab.  It was easy to create from a marrow aspirate.  We performed some basic MRI studies with pre and post 3.0T high field studies and ran outcome questionnaires for knee and hip arthritis patients.  We were unimpressed by the results and because of this experience moved on to culture expanded mesenchymal stem cells.  

 

BMAC has become popular of late. In this procedure, a physician takes a bone marrow aspirate, places it in a specially designed centrifuge and pulls out a concentrate of bone marrow nucleated cells. This has been billed as a stem cell concentrate, but the stem cells that are concentrated in reasonable numbers tend to be CD34+ heme progenitors (stem cells that make new blood) and not MSC’s (Mesenchymal Stem Cells). Since MSC’s are the MVP of the adult stem cell mix available in a bone marrow concentrate, their concentration is very important to the success of such a treatment. A recent study on bedside bone marrow concentrate machines for MSC’s (BMAC) determined what concentrations were possible from a commercially available centrifuge unit. Using this study to calculate MSC numbers, a 60 ml bone marrow draw would produce 70,000-90,000 MSC’s. The Regenexx procedure yields after culture expansion are in the 5M-100M range. Based on this data, the Regenexx procedure produces approximately 100-1,000 times more cells than you can obtain with BMAC bedside systems. Based on this and other data, our best estimate is that the average micro fracture procedure would release 5-10 ml of un-concentrated marrow, so about 500-1,000 MSC’s into the defect site. Our own dosing data and the copious animal research would suggest that for appropriate cartilage, tendon, ligament, muscle repair the necessary MSC dose is in the millions range. Obtaining that amount of MSC’s from a BMAC system would require unacceptably high volumes of whole marrow from the patient. The conclusion, while very convienent, BMAC doesn’t have the right stuff.

For more information on different stem cell types, I’ve posted a video below:

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January 20, 2009

Rotator Cuff Pain Relief Therapy

 

rotator cuff pain relief therapy

rotator cuff pain relief therapy

So you’ve torn your rotator cuff, is there such a thing as rotator cuff pain relief therapy without surgery?  Yes.  First the simple stuff.  If you can’t lift your arm, then you’re likely too injured for this particular blog post (more to come).  However, if you just have pain on lifting, then this blog’s for you.  If you’re in this later category, the good news is that you likely have a partial rotator cuff tear, where the muscle is torn, but not through and through.  We frequently use treatment such as IMS to get rid of the muscle knots and help the pain.  This is where a tiny acupuncture needle is used to eliminate painful portions of the muscle (this is very different than traditional Chineese acupuncture where the muscles aren’t treated). In addition, massage therapy of the supraspinatus, infraspinatus, subscapularis, teres, or upper trapezius may help.  Finally, before you consider surgery, look at one of the newer injection based options to heal the tear with less down time.  For example, the patient’s own stem cells can now be injected into the rotator cuff tear under x-ray guidance, so that no surgery is required.  This gets rid of that big blue pillow immobilizer and the long recovery commonly associated with rotator cuff surgery.  You should give your rotator cuff tear a 4-6 weeks to heal and if it’s staying the same, time to get something done.  The big issue you want to avoid is muscle atrophy, so all of this should be performed with rotator cuff exercises.

January 19, 2009

Exercises that Stress the Rotator Cuff

The rotator cuff provides stability to the shoulder.  The most commonly injured muscle of the four muscles that make up the “rotator cuff” (Supraspinatus, Infraspinatus, Teres, Subscapularis) is the supraspinatus.  Exercises that stress the rotator cuff would focus on use of these four muscles more than other surrounding shoulder muscles (like the trapezius).  To stress the supraspinatus, the empty can maneuver is the best way to go.  Place your arm out to the side with the thumb down like you’re pouring out a can of soda.  The arm should be slightly forward.  If you move your arm up and down from the side of your body to just shoulder level, the muscle being stressed is the supraspinatus.  If this is painful and if when you place the thumb up much of the pain goes away, that’s a good indication that your supraspinatus muscle may be torn or injured.  If you can’t do this at all, it may be completely torn and retracted (not connected).  The infraspinatus and teres can be stressed by movements that externally roate the shoulder and arm (if you place your elbow at your side and start with your hand on your stomach and move it out to the side while keeping your elbow tucked in, that’s external rotation).  The subscapularis goes the other way, it brings the hand in with the elbow tucked into the side.  What if exercises won’t heal the problems?  You might consider some of the newer non-surgical methods that use injections of thepatient’s own stem cells to heal the rotator cuff tear.  The recovery times are much shorter and you can avoid the knife!

Nutrition to Heal Rotator Cuff Injury

Nutrition to heal a rotator cuff injury is all about the building blocks for repair and their helpers.  What are the building blocks?  Collagen and GAG’s (hyaluronic acid for instance) are good places to strat.  Foods that are rich in collogen include Jello.  Vitamins that help support collogen include vitamin C.  Other building blocks include glucosamine and chondrotin sulfate, although these are a bit more joint focused.  One of the big problems with rotator cuff repair is often there is limited blood supply to this area, so getting any nutrients to it can be tough.  Activity can help in this process.  Gentle rotator cuff exercises can help.  How do you know if it’s healed?  Take your arm and place it out to your side with the eblow extended and point your thumb to the ground.  This stresses the rotator cuff.  if you can’t do this or it hurts, then it’s not healed.  Is there a way to get it to heal without sugery, yes newer non-surgical procedures are available (click link).

Torn Shoulder Rotator Cuff

Ruth is like many of our patients with a torn shoulder rotator cuff. She’s a health care professional (nurse) who has had the RIGHT rotator cuff treated twice with traditional roator cuff repair surgery. The several month recovery was difficult, the blue pillow immobilization meant that she couldn’t work as an ER nurse. Because of the muscle atrophy (this means that the sutures from the surgery can hurt local muscle cells, causing them to atrophy and die off) she likely experienced with the first RIGHT sided rotator cuff surgery, she had a retear of the same rotator cuff a few years later. The second time she was again off work for several months and unable to earn her salary. Based on her outcome with her first and second surgeries on the RIGHT, when the LEFT rotator cuff tore (while she was transferring a patient as a nurse), she went searching to see if non-surgical alternatives were available. We treated the LEFT by using her MRI to plan our x-ray guided injections of her own mesenchymal stem cells into the tear. It’s should be noted that this time, she remained working and fully active during the procedures. She has had three injections into her torn shoulder rotator cuff with excellent relief of pain and return of full range of motion. Rather than the doctor continuing to tell what happened, best to let the patient tell her own story:

January 13, 2009

Steroid Shots

Steroid shots have become a mainstay of modern orthopedic medicine.  Relief from a cortisone shotis due to powerful anti-inflammatory effects of the corticosteroid medication.  You body uses this same chemical daily to modulate inflammation and help control tissue repair (generally to put the brakes on an inflammatory injury response).  In very low doses (about 1,000,000 times less than is used by most doctors) these natural steroids help to reduce swelling and help the joint produce growth factors like TGF-beta which can help heal local tissues.  However, in the high doses commonly used in orthopedics (milligrams or bout 1,000,000 times more than the nano-grams used naturally), steroids can be a big sledge hammer to the system, stamping out bad inflammation and good tissue repair with equal force.  A steroid shot for sciatica is common these days, as doctors often use these to decrease swelling around swollen nerve roots that lead to back and leg pain.  however, the same issues as above apply, the dose if often too high.  Our own experience with out own patients shows that relief from a cortison shot can be obtained with a low nono-gram dose approximately 1,000,000 times less than the commonly used milligram dose.  This also prevents many of the body wide side effects that can seen from high dose milligram cortisone shots, such as weight gain, changes in blood sugar, and moodiness.  Cortisone shots before surgery (the higher milligram dose) will generally reduce the effectivness of healing, as they tend to supress the healing immune system response including knocking down critical repair responses and adult stem cells.  Concerned about high milligram dose cortisone shots?  Alternatives treatments include prolotherapy and using your own stem cells to help heal a joint rather than just reducing the inflammation short term.

Cortisone Shot Flare

 

cortisone shot flare

cortisone shot flare

As a pain management doctor who performs procedures all day, I have seen Cortisone shot flares in the office.  Cortisone is a corticosteroid, which is a fancy way of saying that it’s a very strong anti-inflammatory which can bring down swelling.  Cortisone is actually an older brand name, newer brand names more commonly used today include Depomedrol and Celestone.  One of the biggest problems that we see in our office is that the commonly dose used of Cortisone is in the milligram range (thousandth of a gram).  While this may not sound like much, for orthopedic applications like sciatica, back pain, knee pain, shoulder pain, elbow pain, and other peripheral joints, this dose is about 100,000 to 1,000,000 times more than your body naturally uses to control swelling.  As an example, if the 50 nano-gram dose that your joint would use on it’s own to control inflammation is the height of a book of matches, the height of the usual dose used by most physicians to control swelling is the height of the Empire State Building.  Why? Unknown, as the science would support that the nano-gram (billionth of a gram) dose is good for the joint, while the milligram dose causes all natural repair function to cease.  This is why too many of these very high dose Cortisone shots can cause a joint to degrade.  Think of it as you can put in a finish nail with a sledgehammer (the milligram dose), but it isn’t pretty.   Steroid shots for sciatica are common, and we only use the giant milligram dose in certain circumstances where we need a huge effect to help the patient, otherwise we have moved to the lower doses.  So what’s the biggest cause of a Cortisone shot flare? While the high dose may be an issue, it’s usually the needle.  To inject joints, most syringes come loaded with a 20 gauge needle.  While this makes drawing up meds very fast and is great for pulling fluid out of a joint (aspirate), its way to large for putting cortisone into a joint.  A 27 gauge needle is a better choice and less likely to cause a cortisone shot flare.  So to avoid a Cortisone shot flare, make sure your doctor uses a smaller needle (25 or 27 gauge).  In addition, we find that cold spray on the skin can help patients tolerate the shot better.  In addition, having the doctor wiggle or put allot of pressure on the area to be injected can help reduce the sensation of the needle stick.  What if don’t want Cortisone?  Alternatives include prolotherapy and using your own stem cells to help heal a joint rather than just reducing the swelling short term.

January 11, 2009

Shoulder Ligament Injuries

Ligament Tear Symptoms

Ligament Tear Symptoms

MY OWN TORN SHOULDER LIGAMENT TREATMENT: As a very young young doctor many years ago, I thought I knew how to ride a motorcycle (or a donor cycle as my mother called it) and ended up with my right shoulder finding the road. This began my first-hand education of my own shoulder ligament injury. First, an anatomy lesson on shoulder ligaments simplified for non-physicians. The most commonly torn shoulder ligaments in a “separated shoulder” are those that hold the collar bone (clavicle) and top of the shoulder blade (acromion) together. There is an actual joint here, known as the “AC” joint or acromio-clavicular joint. When you injure this joint and the ligaments that hold this top shoulder joint together, it can be a grade 1 (just stretched ligaments, but the joint is still together), grade 2 (stretched ligaments that allow the joint to come apart a bit, but are still intact), or a grade 3 (completely torn-up ligaments that no longer hold the joint together or connect). If you have a grade 3 torn ligament in your shoulder, you’ll know it by the huge step off (often 1/2-1 inch) between the collar bone and the acromion (top of shoulder). If you have a grade 3, then the only long-term solution is to either leave it alone or have an orthopedic surgeon perform a shoulder repair using cadaver ligaments, a tendon graft, or similar to bring it back together. The grade 1’s and 2’s are really the focus of this post. What to do if this continues to pop, click, get sore, and generally hurt? How do you heal these torn ligaments in the shoulder? After a few years of not being able to go back to weight lifting, I tried prolotherapy on mine, and it worked reasonaly well (not a complete fix, but better). This is where the doctor injects substances that cause a brief inflammatory healing reaction in the ligaments. What would I do if I injured it today and it wasn’t getting better, no doubt I’d try some of the adult stem cell procedures where we can take your own stem cells and inject them into the ligaments to reapir the damage. In addition, if you have a partial rotator cuff tear (not uncommon), the same can be done to heal that as well. I have posted videos at the end of this discussion on a shoulder rotator cuff tear and ankle ligaments healed this way. What would I stay away from? The knife and shoulder ligament surgery! For a grade 1 and grade 2 shoulder ligament injury, in my opinion, there is no rationale for surgical repair, given these other treatment options. There are various links above for more information. Why do you want to get the ligaments fixed in some way? because if you don’t, the AC joint will develop arthritis and start pressing on the rotator cuff muscles leading to a chronic shoulder problem that will need surgery one day.

My shoulder? No perfect, but since I went back to lift very heavy weights as a weight lifter, you can guess it’s much much better than it was prior to treatment. I have never had surgery and am doing fine some 20 years after the injury.



January 8, 2009

Bone Stimulators

As a doctor, patients with a fracture that won’t heal can be in quite a pickle. There are many bone stimulators on the market including the Exogen, the Symphony bone growth stimulator, and the mbi bone growth stimulator. How does a bone stimulator work ? There are two main types, ultrasound based and an electrical bone stimulator. The ultrasound type works by emitting a pulsed low intensity ultrasound signal (PLIUS). This has been shown to stimulate mesenchymal stem cells which turn into osteoblasts which are cells that make new bone. An electrical bone growth stimulator works in much the same way. It’s usually worth using one of these units for 6-12 weeks. What if using a bone stimulator doesn’t work? Bone grafting is one option, but a big surgery. Is there another way? Yes, newer stem cell based injection methods can avoid the surgery and use your own stem cells to heal the fracture. I’ve posted two videos below on the subject:

electrical stimulation for fracture healing

As a doctor, one of the most difficult problems a patient can face is is a bone that won’t  heal.  One of the most miserable patients I can rememeber was a little old lady with a sacral fracture who at three months after her fracture couldn’t even go to physical therapy because the fracture wasn’t healing.  She had tried electrical stimulation for fracture healing, but this failed.  Other patients who come to mind are a thirty something smoker with an non-healing humerus fracture and a 60 something geologist with a leg fracture (tib-fib non-union).  They all had one thing in common, they could barely do anything.  What other options are there for these patients?  One option is as we’ve discussed, electrical stimulation for fracture healing.  There are also other types of fracture healing assist devices, including PLIUS or Pulsed Low Intensity Ultrasound.  These units can help, but what to do when they fail?  The issue is often a poor blood supply to the fracture.  As a result, surgeons traditionally try a bone graft with it’s own blood supply.  However, this is a very big surgery.  Is there another way to heal these fractures that won’t heal on their own?  Yes, recent research into adult stem cells have shown them capable of fracture repair.  How did we heal up the three fractures described above?  By injecting the patient’s own adult stem cells into the fracture lines (without bone graft surgery).  The little old lady?  Independent in 6 weeks with a healed scaral compression fracture.  The smoker?  Healed in 6 weeks and had full function of her arm.  The 60 some year old geologist with the tib-fib non-union?  Same.  All without surgery.  Below is a video that explains more:

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