What is Regenerative Medicine?
Regenerative Medicine as it applies to the world of Musculoskeletal medicine is also referred to as ORTHOBIOLOGICS. It includes the use of Platelet Rich Plasma, Stem Cell, and other cell-based orthopedics for injuries of bone, muscle, tendon, cartilage, ligament.
The use of regenerative treatments dates far back in history to ancient Egyptians. In modern medicine, there are now over 20 years of research studies showing undisputedly the distinct advantage of regenerative medicine for improving pain.
Shoulder
Shoulder surgery is particularly difficult as it is a complex joint. Post-surgical recovery can be painful, requiring a lengthy rehab period to restore strength and mobility to the shoulder. As an alternative to shoulder surgery, regenerative procedures help alleviate shoulder pain and restore joint damage with a non-invasive injection procedure. You can do this without a lengthy rehab or time off from work.
One study concluded that larger rotator cuff tears were associated with less pain and that more pain was accurately predicted by more IL-8 (interleukin 8) in the joint fluid. IL-8 is an inflammatory cytokine, an alarm sounding when inflammation is present. The pain in this study was due to the inflammation, not the tear itself.
At an American Academy of Orthopedic Surgeons meeting a few years ago, research was presented that demonstrated that large rotator cuff repairs that were repaired surgically restore at a rate of 57% in a series of 500 patients—that’s nearly 6 out of 10 rotator cuff surgery failures. The researchers demonstrated that the repairs with the largest tears were more likely to tear again.
Shoulder dislocation surgery recovery time can be anywhere from 3–6 months with limited movement of the joint. And a full return to sports, if it happens at all, is not likely to happen until 6–12 months after surgery.
Using a precise, image-guided injection of the patient’s own stem cells and growth factors, we are able to get more of the body’s natural “repairmen” directly into the tear. By mobilizing the body’s own healing mechanisms, Regenerative medicine has produced good results in the treatment of partial rotator cuff tears, and has even shown encouraging success with completely retracted tears; shoulder arthritis; shoulder tendonitis; recurrent dislocations; joint separation; and other shoulder issues.
References:
- Systematic Review: Nonoperative and Operative Treatments for Rotator Cuff Tears; Jennifer Seida et al. Annals of Internal Medicine 2010 Aug; Volume 153, Issue 4 Page: 246-255.
- Shoulder pain and intra-articular interleukin-8 levels in patients with rotator cuff tears
- Koichi Umara et al. Int J Rheum Dis 2017 Feb;20(2):177-181.Epub 2015 Apr 30.
- Steroid Shots Bad for Tennis Elbow Long Term; Crystal Phend.Orthopedics 2010
- Shoulder function not fully restored after surgery;
- Henry Ford Health System 2010 March
- Regenexx.com
Knee
Regenerative medicine is a non-surgical treatment that use your body’s own healing agents to treat knee arthritis and injuries, including meniscus tears and torn ACL. Our patients benefit from reduced pain and improved function, helping them avoid surgery and knee replacement.
In 2008 Regenerative Medicine first got a lot of attention in the U.S. when HINES WARD of Pittsburg Steelers sustained an injury to his MCL (medial collateral ligament) and was treated
with Platelet Rich plasma. He went on to recover to peak performance and became super bowl MVP.
For knee OA, it has been shown repeatedly undisputedly to be better than hyaluronic acid injection
ACL Tear Repair Without Surgery
Approx. 70% of ACL tears can be healed without surgery1 Our goal is to use your body’s own healing power to save your ACL, not replace it.
CAN STEM CELLS REGROW CARTILAGE?
No. Real knee stem cell therapy won’t regrow large stretches of cartilage; however, they will:
- Optimize and change the environment. The environment inside an arthritic joint has a mix of inflammatory and damaging chemicals.
- Replace stem cell reserve. The number of those cells available for repair and maintenance goes down as we age and get arthritis.
- Recharge and rejuvenate dying stem cells. Studies have shown that mesenchymal stem cells can give their good batteries (mitochondria) to cells that have worn-out batteries, giving new life to those dying cells.
- Treat bone lesions and microfractures which are a common source of pain
References
- Regenexx Patient Registry – Knee Outcomes. Lower Extremity Functional Scale (LEFS) questionnaire. Accessed on November 02, 2020.
- Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002 Jul 11;347(2):81-8.
Englund M, Guermazi A, Gale D, Hunter DJ, Aliabadi P, Clancy M, Felson DT. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008 Sep 11;359(11):1108-15.
Katz JN, Brophy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm DL, Donnell-Fink LA, Guermazi A, Haas AK, Jones MH, Levy BA, Mandl LA, Martin SD, Marx RG, Miniaci A, Matava MJ, Palmisano J, Reinke EK, Richardson BE, Rome BN, Safran-Norton CE, Skoniecki DJ, Solomon DH, Smith MV, Spindler KP, Stuart MJ, Wright J, Wright RW, Losina E. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2;368(18):1675-84.
Sihvonen R, Englund M, Turkiewicz A, Järvinen TL; Finnish Degenerative Meniscal Lesion Study Group. Mechanical Symptoms and Arthroscopic Partial Meniscectomy in Patients With Degenerative Meniscus Tear: A Secondary Analysis of a Randomized Trial. Ann Intern Med. 2016 Apr 5;164(7):449-55.
van de Graaf VA, Noorduyn JCA, Willigenburg NW, Butter IK, de Gast A, Mol BW, Saris DBF, Twisk JWR, Poolman RW; ESCAPE Research Group. Effect of Early Surgery vs Physical Therapy on Knee Function Among Patients With Nonobstructive Meniscal Tears: The ESCAPE Randomized Clinical Trial. JAMA. 2018 Oct 2;320(13):1328-1337.
- Regenexx Patient Registry – Knee Outcomes. Numeric Pain Scale (NPS) questionnaire. Accessed on November 02, 2020.
- Regenexx Patient Registry – Knee Outcomes. Single Assessment Numeric Evaluation (SANE) questionnaire. Accessed on November 02, 2020.
- NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases. Accessed October 5, 2020.
- Arthritis Foundation. Accessed November 02, 2020.
- Xia Z, Ma P, Wu N, Su X, Chen J, Jiang C, Liu S, Chen W, Ma B, Yang X, Ma Y, Weng X, Qiu G, Huang S, Wu Z. Altered function in cartilage derived mesenchymal stem cell leads to OA-related cartilage erosion. Am J Transl Res. 2016 Feb 15;8(2):433-46.
- www.Regenexx.com
Hip
We provide cutting edge non-surgical treatments that use your body’s own healing agents to treat and repair injuries including hip osteoarthritis, avascular necrosis, labrum tears, tendon tears, hip bursitis, other degenerative problems related to the hip.
We use image guidance (fluoroscopy and ultrasound) to very precisely place high dose stem cells or platelets from your body directly where they are needed in a specific joint structure. These cells then work in the site of your injury to grow into new, healthy tissue, a process that will only occur if the cells have been placed exactly where they need to go in order to achieve positive outcomes for the patient.
One study finding that 45% of patients that underwent hip arthroscopic surgery had poor results at an average of five years post-surgery. The results from surgery are even worse when a patient has even minimal hip arthritis.
Arthritis worsened in six of 10 patients when even a minimal amount of arthritis was present. This is in spite of surgery
Hip surgeries are especially traumatic and require months of painful recovery while patients redevelop strength and mobility and won’t increase your level of activity. Common arthroscopic hip surgeries are comparable to results with no surgery and hip replacements wear out and require revision especially for younger patients.
Surgical recommended intervention for chronic tendon pain and tightness can involve sewing together tears, cutting the tendon to try to get it to heal, or lengthening a tight tendon. While this approach may lead to relief of the tightness and surrounding symptoms, the body is precisely balanced, and the shortening or lengthening of the tendon often leads to other problems. Moreover, whatever biomechanical problem led to the initial tendon injury has not been resolved.
References:
- Efficacy and Safety of Bone Marrow Concentrate for Osteoarthritis of the Hip; Treatment Registry Results for 196 Patients. Christopher J Centeno et al. J Stem Cell Res Ther 2014, 4:10 DOI: 10.4172/2157-7633.1000242.
- Treatment for hip conditions should not rest solely on MRI scans; American Orthopaedic Society for Sports Medicine. Bradley C. Register et al. Steadman-Philippon Research Institute 2012,
- Association of cartilage defects, and other MRI findings with pain and function in individuals with mild-moderate radiographic hip osteoarthritis and controls; Deepak Kumar et al. Osteoarthritis Cartilage 2013 Nov;21(11):1685-92.
- Regenexx Patient Registry – Hip Outcomes. Accessed Nov 2020
- Regenexx.com
Myofascial Pain
Myofascial pain syndrome is a chronic pain disorder. In this condition, pressure on sensitive points in your muscles (trigger points) causes pain in the muscle and sometimes in seemingly unrelated parts of your body. This is called referred pain.
Signs and symptoms of myofascial pain syndrome may include:
- Deep, aching pain in a muscle
- Persistent or worsening pain
- A tender knot in a muscle that reproduces pain
- Difficulty sleeping due to pain
Myofascial pain syndrome is caused by a trigger such as muscle tightness, that sets off trigger points in your muscles. Factors that may increase your risk of muscle trigger points include:
- Muscle injury.An acute muscle injury or continual muscle stress may lead to the development of trigger points. Repetitive movement and poor posture also increase risk.
- Stress and anxiety.People who frequently experience stress and anxiety may be more likely to develop trigger points in their muscles. These people may be more likely to clench their muscles, a form of repeated strain that leaves muscles susceptible to trigger points.
Injecting a numbing agent or a steroid into a trigger point can help relieve pain. In some people, just the act of inserting the needle into the trigger point helps break up the muscle tension. Called dry needling, this technique involves inserting a needle into several places in and around the trigger point.
Injecting Platelet Rich Plasma (PRP) has been shown to be beneficial in treating trigger points resulting in long term pain relief. Substances in PRP such as Alpha-2-Macroglobulin and Interleukin-1-receptor antagonist are nourishing to muscle cells or myocytes.
References:
- Platelet-Rich Plasma Intramuscular Injections – Antinociceptive Therapy in Myofascial Pain Within Masseter Muscles in Temporomandibular Disorders Patients: A Pilot Study. Nitecka-Buchta A, et al. Front Neurol. 2019 Mar 19;10:250.
- Pathophysiology of Trigger Points in Myofascial Pain Syndrome
- Sarah Money. J Pain Palliat Care Pharmacother. 2017 Jun;31(2):158-159.
- mayoclinic.org
Spine
We provide a non-surgical alternative that uses your own cells to repair the damage.
Steroid injections that place steroid medication around irritated or inflamed nerves in the spine do help patients avoid surgery for a time. However, repeat high dose steroids can also cause severe side effects and actually reduce the body’s ability to heal. This ultimately leads to degeneration of the tissue and increases the likelihood of needing surgery.
Spinal fusion is a highly invasive and irreversible procedure that has a significant risk of complications. A study showed that complications occur in 36% of fusion patients while 76% are still dependent on narcotics following their recovery from surgery. Surgical patients also miss three times as much work as those who don’t have surgery. A simple injection of your own cells, by contrast, has less than a 0.1% risk.
Disc surgery can weaken that structure and it can re-herniate. In a fusion surgery, a procedure where part of the spine is bolted together solid, the structures above and below can get overloaded and torn up and this problem is known as adjacent segment disease.
The risks associated with these surgeries is very real. The complication rate for fusion surgeries is as high as 25%. Furthermore, most patient continue to need controlled opioids for pain and miss three times as much work as those who don’t have surgery.
Additionally, fusions lead to the increased mechanical stress and wearing down of the segments above and below the fusion site as those segments now take on more movement than they were designed to accommodate, potentially leading to the need for additional fusions over time.
Precise, injection-based treatments of growth factors or your body’s own healing cells that focus on treating the whole spine. For example, if you’ve had a prior disc surgery that didn’t work, we can inject using real-time imaging to help heal damaged nerves. Of if you have a fusion, our goal will be to strengthen and heal the damage happening because of the increased wear and tear. Best of all, your downtime will be a fraction of surgery, with little to no need for opioid pain medications or time off of work. Call today to get started on your path to recovery.
References:
- Long-term outcomes of lumbar fusion among workers’ compensation subjects: a historical cohort study. Trang H Nguyen et al Spine 2011 Feb 15;36(4):320-31.
- Use of prescription opioids before and after an operation for chronic pain (lumbar fusion surgery) Richard E Deyo et al. Pain 2018 Jun;159(6):1147-1154
- Chronic opioid use following anterior cervical discectomy and fusion surgery for degenerative cervical pathology. Harris AB et al. Spine J. 2020 Jan;20(1):78-86.
- Regenexx Patient Registry – Spine Outcomes. Accessed on November 30, 2020.
- Regenexx.com
Concepts in Regenerative Medicine
Concepts in Regenerative Medicine
What is Normal Healing?
There are 3 phases of wound healing:
ACUTE INFLAMMATORY PHASE: last up to 1 week
PROLIFERATIVE PHASE: Body replicates and lays down new tissue. This is immature and disorganized tissue
MATURATION: Body takes disorganized tissue and organizes it into healthy tissue.
Interruption of this process results in scar tissue, chronic inflammation as well as tissue that lacks tensile strength
Platelets
These are the 1st responders of the body
They sit in the circulatory system and travel to the site of injury once some signaling chemicals are released.
They secrete Growth Factors and Cytokines. These recruit stem cells.
They create a very powerful signaling mechanism resulting in stopping the chronic (bad) inflammation and promoting healing
Platelets are also antimicrobial and help protect against infection
Platelets also have filipodia (feet/tentacles). When these filipodia are activated they pull together pieces of tissue and act like a suture.
In this way Platelets jump start normal healing.
WE ARE CAPTURING THE POWER OF PLATELETS
Platelet Rich Plasma
A sample of autologous blood (blood from the same person) processed to increase the concentration of platelets over baseline
Centrifuge
A machine that spins very fast (about 3600 revolutions per minute) and uses force over gravity to separate blood into its components
PRP has best evidence for:
- KNEE, HIP, SHOULDER OA
- Tendonitis and tendon tears
- Rotator cuff
- Tennis elbow
- Hamstring tendon
- Gluteus Medius
- MCL, ACL
- Achilles tendon
- Intradiscal injection into lumbar spine
Stem Cells
What Is A Stem Cell?
An undeveloped biological cell that is capable of multiplying and differentiating.
Embryonic Stem Cell
It is pluripotent. It can develop into any type of tissue. This poses some ethical concerns
Adult Stem Cells
These are also called mesenchymal stem cells. Are multipotent. They can develop into FAT, MUSCLE, CARTILAGE, BONE, BLOOD VESSELS. These can be stored and used for maintenance and repair.
How Stem Cells Work
Usually in arthritic conditions, articular cartilage is being eaten away by bad molecules called activated macrophages (Cytokines, prostaglandins and matrik metalloproteases)
They have a PAC MAN like effect munching away at articular cartilage.
Stem cells and platelets secrete substances with a powerful signaling mechanism:
PDGF TNG
Veg 1 BNP
VL1RA
These have an anti-inflammatory, anabolic, tissue repair effect and improve blood flow. They change the way the immune system perceives the joint and stop cell death, stop pathway of degradation
BMAC (Bone Marrow Aspirate Content)
Stem cell derived from your own bone marrow
SVF (Stromal Vascular Fraction)
This creates a stem cell product from fat. Collagenase is added to emulsify fat and obtain the stromal vascular fraction. Presently FDA consider this manipulation and illegal.
Cell Culture
Put Cells in a vessel and give them a nutrient rich “broth” and they grow.
Bone Marrow Aspiration is very safe. They retrospectively looked at 19,000 patients in the U.K. (< 1% complication rate with bone marrow aspiration. That 1% had other comorbidities such as leukemia and blood clots)
This is safer than getting stem cells from a fat source. Liposuction has a 7% complication rate.
Autologous: Means coming from your own body
Allogenic: Coming from someone else
BUYER BEWARE!
AMNIOTIC AND CORD BLOOD PRODUCTS HAVE NO LIVE STEM CELLS!!!
These are sold as stem cell products but this is deceptive. In order to be safely used, these have to undergo gamma radiation and be pulverized. Upon inspection of these products, no live cells have been identified.
At best, these so-called stem cell treatments have only growth factors and other substances.
A CAUTIONARY TALE…
Liveyon was a company that claimed to sell umbilical cord products with live and functional mesenchymal stem cells. The CEO started this company 4 days after leaving prison. A liveyon shipped product caused bacterial contamination which caused a dozen patients to end up in the ICU
FDA Regulation
Presently Regenerative Medicine is not FDA approved
This is probably because this field is presently a regulation nightmare for the FDA
It is like the WILD WEST.
These are a lot of practitioners with unscrupulous practices. There are some acupuncturists, chiropractors and naturopaths in this field, which is against their natural practice acts. It has become like “WHACK A MOLE” for the FDA. Proposed FDA regulations were set back by COVID-19. FDA will be enforcing regulations soon
In the News
Use of Ultrasound for Precision
This is critical if you want results. There are some important factors that give you a vastly superior outcome. Your physician needs to:
- Obtain highest quality of PRP or stem cells and use techniques to optimize their viability.
- Use ultrasound guidance to do very specific targeted injections.
- Inject surrounding and supportive structures comprehensively
A CONCEPT CALLED BIOSYNTEGRITY
Derived from the term SYNTEGRITY taken from the architecture world. This is how tall buildings and big bridges are built. Cohesiveness of entire structure is needed. Tendons, ligaments, fascial planes and muscles need Mobility and stability in every ROM. This is a Dynamic stabilizing process, complex interplay of communication and control
They way this applies to regenerative medicine treatments is that you want to treat at each and every single defect.
You need a 3D approach to strengthen different tissue layers.
This is why being adept at and injecting with ultrasound guidance is so critical.
Dr Chahal works hard helping me get a handle on my chronic pain issues. She actively discusses all the most current medical opportunities available for my various conditions. She is very understanding and empathetic to my pain issues. I highly recommend her.
Great expert and care! Dr. Manisha provided clear information about causes and treatment offered. Excellent Doctor.
First appointment with Dr. Chahal. She was very thorough, and explained my diagnosis and treatments. I look forward to seeing her again and highly recommend her.
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At BeVITAL Wellness Center, health is our priority
At BeVITAL, Dr. Manisha Chahal and her team focus on helping you achieve your best self. With the industry experience of several years, the team has helped many in pain relief and finding health.