Sports Medicine Dr Pete Biglin DO Conflict of Interest In compliance with continuing education requirements all presenters must disclose any financial or other associations with companies to which they have a direct link andor financial relationship that is related to the topiccontent of t ID: 779230
Download The PPT/PDF document "Stem Cells & PRP in" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Stem Cells & PRP in
Sports Medicine
Dr. Pete Biglin, DO
Slide2Conflict of Interest
In compliance with continuing education requirements, all presenters must disclose any financial or other associations with companies to which they have a direct link and/or financial relationship that is related to the topic/content of their presentation.
None
Slide3Overview of Healing process
TYPE OF HEALING:
EXAMPLES:
Biologic-natural
Humans “regenerate” cells on a daily basis to replenish body systems. Tissues regenerate naturally- even the elderly. Humans have intrinsic capability of healing.
Rehabilitation
Can facilitate healing response. Examples: ROM, stretching, strengthening, cross fiber massage, eccentric loading
Surgical repairACL repair, ORIF………etc.Othernutrition, chiropractic, acupuncture…….etc.Experimental “Orthobiologics”Platelet Rich Plasma, and Stem cell treatments
PM&R 7 (2015) S1-3
Slide4“Orthobiologics”- can we harness our bodies healing capacity?Various biologic agents obtained directly from our own bodies taping into our own intrinsic capacity to heal
Treatment of various orthopedic conditions is possibleExact mechanism of action is unknownBasic science evidence points more toward enhancing local environment, & upregulating healing factors – as opposed to replacing new tissues Types:Platelet Rich Plasma (PRP)
Stem Cell Treatments
PM&R 7 (2015) S1-3)
Slide5Stem Cell Treatments
Slide6What are Stem Cells?
Slide7TYPE OF STEM
CELL
:
WHAT IT CAN BE
:
EXAMPLES
:
TOTIPOTENT
CELLS
NEW HUMAN
CELLS OF THE EMBRYO
1-3 DAYS
PLURIPOTENT CELLS
ANY CELL
TYPE
CELLS OF BLASTOCYST 5-14 DAYS
MULTIPOTENT CELLS
(ADULT STEM CELLS)
MANY DIFFERENT
TISSUE CELL TYPES
MATURE
FETUS, CORD BLOOD & ADULT CELLS
TOTIPOTENT EMBRYONIC CELL
PLURIPOTENT CELL TYPES:
ENDODERM
MESODERM
ECTODERM
ORGANS
HEART,BLOOD
*MUSCLE, SKIN, BONE
“
MESENCHYMAL STEM CELLS (MSC)
”
BASIC SCIENCE OF STEM CELLS
Slide8TOTIPOTENT CELLS
&PLURIPOTENT CELLS
(EMBRYO)
MULTIPOTENT CELLS
(ADULT
STEM CELLS)
PROS
EASY TO ISOLATEUNLIMITED SELF RENEWALLESS LIKELY TISSUE REJECTIONLESS ETHICAL ISSUESSAFER?
CONS
RISK
OF TISSUE REJECTION
ETHICAL ISSUES (EMBRYO)
POSSIBLE TERATOMA (TUMOR) FORMATION
HARD TO ISOLATE
LIMITED DIFFERENTIATON
Slide9ADULT STEM CELLS-MSCDifferentiation or “MULTIPOTENCY potential”:
Osteoblasts (bone, cartilage)Adipocytes (fat)Chondrocytes (cartilage)Myocytes (muscle)Neurons (nerve)
Slide10INDUCED PLURIPOTENT
STEM CELLS (iPS):
Lab techniques transforming adult stem cells to “Pluripotent” for research . Animal studies currently.
nih.gov
Slide11ADULT STEM CELL-Sources
Bone MarrowUmbilical CordAdipose tissueMolar Cells (teeth)
BMAC Procedure
Slide12Potential Stem Cell Uses in Sports
Ligament TendonCartilageMuscle tissueSpine
Slide13Other potential uses for Stem CellsStroke
Brain injuryAlzheimer’sMissing teethWound healingBone marrow transplantsSpinal cord injury
OA, RA
Nonunion fractures*
Baldness
Blindness
ALS
Heart attacksMuscular DystrophyDiabetesMSCancer
Slide14ADULT STEM CELL DELIVERY
Sources (harvesting):BMAC-bone marrow aspiration concentrate (autologous)
Fat cell liposuction (autologous)
Cryogenic stored Umbilical cord blood from a donor (allogeneic
)
Delivery Process
:
Intravenous (e.g. Cancer treatment)Local delivery (e.g. injection into joint or ligament)
Slide15BONE MARROW HARVESTING
15-20 minute office based procedure
Done with local anesthetic
60-90 cc obtained-yields 4cc BMAC after centrifuge
Slide16BONE MARROW (
STEM CELLS
)
AND/OR
PERIPHERAL BLOOD (
PRP
)
CENTRIFUGE
INJECT
Slide17Mayo Clinic study August 2016
1
st
ever
prospective, blinded, placebo controlled
clinical study to test bone marrow adult stem cells to reduce knee pain
American Journal Sports Medicine Aug 2016
Slide18Mayo Clinic study August 2016
Methods:25 patientsBMAC one knee & Saline injected contralateralPain score 1 week, 3 mo. & 6 mo.
Results:
No adverse events
Pain relief ”dramatic” in BOTH knees
American Journal Sports Medicine Aug 2016
Slide19Mayo Clinic study August 2016Conclusions:BMAC procedure is SAFE
Pain relief similar in BOTH knees-making results somewhat uninterpretableFuture studies needed:Mechanism or actionDuration of efficacyFrequency of treatmentsRegenerative potential to regrow cartilage etc.
American Journal Sports Medicine Aug 2016
Slide20SOME
STEM CELL STUDIESBODY PARTNOTES
Efficacy of autologous bone marrow concentrate for knee osteoarthritis with and without adipose g
raft. Biomed Res Int. 2014;2014:e370621
KNEE OA
840 procedures,
Encouraging
outcomeLow rate AEsNo added benefit with adiposeA Prospective, Single-Blind, Placebo-Controlled Trial of Bone Marrow Aspirate Concentrate for Knee Osteoarthritis. American Journal Sports Med. August 2016KNEE OA1st ever prospective, blinded, placebo controlled clinical study
Concentrated Bone Marrow Aspirate for the Treatment of Chondral Injuries and Osteoarthritis of the Knee
A Systematic Review of Outcomes
KNEE
OA
Lack of high quality studies
Level of evidence 4
Most studies showing a safe procedure with good results
Slide21ADULT STEM CELLSOPEN Scientific Questions
:“Homing” (peripheral IV or local injection)Culturing –growing more stem cells (currently FDA restricted)Applications (Diagnosis specific) Mechanism of Action (surface receptors)
Possible Cancer progression
–
not shown with adult stem cells
Immune reactions (allogeneic donor)
Slide22Current FDA restrictions on Stem CellsFDA restrictions prevent manipulation of culture expansion of stem cells.Adipose tissue- can have higher #s of MSC
– however, isolating the stem cells requires enzymatic digestion of the aspirated adipose tissue, which is currently prohibited by the FDABottom line: Stem Cells can be harvested but not manipulated -“more than minimal” ; Centrifuge, adding water, crystalloids, cutting and shaping of autologous cells is allowed – thereby exempt
from FDA regulation.
PM&R 7. (2015) S60-S65
Slide23PRP Treatments
Slide24What is PRP “Platelet Rich Plasma” ?Derived from peripheral blood draw (60 cc) which is then placed in a centrifuge yielding plasma with concentrated number of platelets (3-4 cc)
Potential benefits:Promote the body’s healingRemove scar tissue
Promote tissue regeneration
Reduce inflammation
Slide25Potential PRP Mechanism of Action?
Therapeutic potential of PRP based on growth factors released from platelets in “supraphysiologic” amounts that can augment the body’s natural healing response.Growth factors from PLT (released from alpha granules) attract stem cells, macrophages, fibroblasts cells promote removal of degenerated/necrotic tissue and enhance tissue regeneration and healingPlatelets also contain signal proteins, growth factors, chemokines, cytokines, and bioactive factors that initiate & regulate the inflammatory cascade.
PM&R (2015) S53-S59
Slide26Centrifuge of Blood- PRP injectionsGoals:
Maximize Platelet ConcentrationMinimize RBC % (possibly cytotoxic to cartilage cells)Minimize WBC % - if doing intra-articular injections. However, WBC may need to be increased in soft tissue injections for potential debridement aspects (Macrophage stimulation)
Centrifuged
Blood
% WBC & RBC obtained can be modified
PM&R (2015) S535-S59
Slide27BONE MARROW (
STEM CELLS
)
AND/OR
PERIPHERAL BLOOD (
PRP
)
CENTRIFUGE
INJECT
Slide28SOME PRP STUDIES
BODY PARTOUTCOME
Treatment of chronic elbow tendonosis with buffered PRP. Am J Sports Med 2006;34:1774-1778
TENNIS ELBOW
BENEFICIAL
PRP significantly improves clinical outcomes in patients with chronic tennis elbow. Am J Sports Med 2014; 42:463-471
TENNIS ELBOW
BENEFICIALTreatment of partial ulnar collateral ligament tears in the elbow with PRP. Am J Sports Med 2013;41;1689-1694ULNAR COLLATERAL LIGAMENTBENEFICIALOne year follow up of PRP treatment in Chronic Achilles tendinopathy: A double blinded randomized placebo controlled trial. Am J Sports Med 2011; 39: 1623-1629 ACHILLES TENDONNOT BENEFICIALActa Chir Orthop Traumatol 2013;80:278-283INTRA-ARTICULAR KNEE INJECTION - OA
PRP SUPERIOR
BENEFIT OVER VISCO-SUPPLEMENTATION
Slide29ConclusionPRP: showing promise in refractory tendinopathies & the modulation of pain and inflammationStem Cell treatments
: emerging studies that support the potential benefit of mesenchymal stem cells for cartilage disorders including osteoarthritis and other MSK conditionsOrthobiologics are a ”highly touted rookie” with a lot to prove
PM&R 7 (2015) S1-S3