the future of medicine and pain relief -...
TRANSCRIPT
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The Future of Medicine and Pain Relief
Christopher Sahler, MD
February 22nd, 2017
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Objectives
• Define Regenerative Medicine
• Discuss the types of therapies
• Clinical applications
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A Quick Word of Caution
• This lecture is NOT intended to replace individualized medical advice
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Chronic Pain Orthopedic Conditions
• Decrease quality of life
• Limit functionality
• Impair sleep
• Interfere with activities of daily living
• Prevent exercise
• >$500,000,000,000 in healthcare cost and lost wages within the United States alone per year.
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Standard Treatment Algorithm
• Tier 1 – PRICE (Protect, Rest, Ice, Compression, Elevation) – Bracing – Physical therapy – Oral/topical medications – Massage, chiropractic care, acupuncture
• Tier 2 – Injections
• Steroid (‘Cortisone’) • Viscosupplementation (gel injections)
• Tier 3 – Surgery
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“Isn’t there something else?”
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Regenerative Medicine
• Regenerative medicine is a multidisciplinary field using molecules, growth factors, cells, or tissues to enhance the healing potential of the body and to restore normal function of the tissue.
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Who Receives Regenerative Medicine Treatment?
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You?
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Regenerative Medicine Therapies
• Platelet Rich Plasma (PRP) ←←←
• Platelet derived growth factor (PDGF)
• Stem cells ←←←
• Prolo Therapy
• Whole Blood
• Amniotic membrane derivatives
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What is Platelet Rich Plasma (PRP)?
• Blood has multiple components: liquid (called plasma), and cells (red cells, white cells, and platelets.)
• PRP is plasma with a higher than normal concentration of platelets (10x more).
• Platelets also contain numerous growth factors which are very important in the healing of injuries.
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How is PRP Administered?
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How is PRP Administered?
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Normal Healing
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Deranged Healing
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Deranged Healing
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How Does PRP Work?
• Injections place increased concentration of growth factors from the PRP into the damaged tissue to potentially speed up OR restart the healing process.
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Regenerative Medicine Therapies
• Platelet Rich Plasma (PRP) ←←←
• Platelet derived growth factor (PDGF)
• Stem cells
• Prolo Therapy
• Whole Blood
• Amniotic membrane derivatives
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Stem Cells
Differentiated versus Undifferentiated cells
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Types of Stem Cells
– Mesenchymal stem cells
– Hematopoietic stem cells
– Mammary stem cells
– Intestinal stem cells
– Endothelial stem cells
– Neural stem cells
– Olfactory stem cells
– Neural crest stem cells
– Testicular cells
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Bone Marrow Aspiration
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Stem Cell Preparation
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Stem Cell Preparation
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How are Stem Cells Administered?
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How do Stem Cells work?
Orchestrate the process of differentiation with differentiated and undifferentiated cells
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Applications of Regenerative Medicine
• 1. Shoulders
• Partial Rotator Cuff Tears
• Glenoid Labrum Tears
• Joint Arthritis
• Fractures
• 2. Elbow
• Medial Epicondylitis (Golfer’s Elbow)
• Lateral Epicondylitis (Tennis Elbow)
• Ulnar Collateral Ligament Injury
• Partial Tear Distal Biceps Tendon
• Fractures
• 3. Wrist/Hand
• DeQuervain's Tenosynovitis
• Joint Arthritis
• Tendonitis of the Wrist and Hand
• Fractures
• 4. Hip
• Joint Arthritis
• Labrum Tear
• Trochanteric Bursitis
• Osteonecrosis of the Femoral Head
• Iliopsoas Bursitis and Tendonitis
• Iliotibial Band Tendonitis
• Fractures
• 5. Knee
• Joint Arthritis
• Rheumatoid Arthritis
• Meniscus Tears
• Patella Tendonitis
• Major Ligament strains or partial tears (MCL, LCL, ACL)
• Chondromalacia Patellae
• Quadriceps Tendon Strain or Partial Tear
• Osgood-Schlatter Disease
• Fractures
• 6. Ankle / Foot
• Achilles Tendonitis and Partial Tears
• Peroneal Tendonitis and Partial Tears
• Posterior Tibial Tendonitis and Partial Tears
• Plantar Fasciitis
• Joint Arthritis
• Recurrent Ankle Sprains
• Fractures
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Osteoarthritis
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Osteoarthritis
• Osteoarthritis affects over 25 million adults
• Inject PRP into the knee
• When compared to placebo or hyaluronic acid injections (aka ‘gel injections’, viscosupplementation); PRP often shows better outcomes in reduced pain and increased function.
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Tennis Elbow
• Some studies have shown that PRP is more effective than a cortisone injection
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Discogenic Back Pain
• Adults with chronic low back disc pain
• PRP injection into the disc had improved functional and pain outcomes versus placebo
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Tendinitis
• Tendinitis at the triceps, biceps, elbow, hamstring, gluteal muscles, patella, Achillies and Plantar Fascia
• One study found 82% of the patients had moderate to complete improvement in their symptoms with PRP injections.
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Post-procedure protocol
• No icing for 2 weeks
• No NSAIDs for 2 weeks
• The pain could be worse for the first week. This is normal and not to be concerned about
– Tylenol or pain medication
• May start to feel improvement weeks 4-6
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Post-procedure protocol
• Days 0-2 –Non/partial weight-bearing for lower extremity procedures, sling for UE
• -Active range of motion multiple times per day.
• Days 3-14 -Weight-bearing activity as tolerated
• Wean off crutches, boot, splint; active range of motion
• Weeks 2-4 - Isometric strengthening exercises
• -Passive stretching; Stationary bike with light resistance
• Weeks 4-6 –Concentric strengthening exercises
• -Elliptical machine or stationary bike with moderate resistance
• Weeks 6-10 -Eccentric exercise based upon the
• -Walking program progressing to jogging and may stand and use heavy resistance while bicycling
• Weeks 10-12 -Plyometrics and sports-specific training
• Weeks 12 -Unrestricted activity
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Stem Cells and Joint Pain
• Studies that have been performed so far are often associated some type of surgical procedure
• Seems to be benefit especially when some type of scaffolding used.
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Stem Cells and Tendons
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Higher upside with Stem Cells
• Generate new tissue
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A few take home points
• It is important to note that the available research on these therapies is still considered limited and at times inconclusive or even contradictory.
• Additional research is needed to verify their affects and standardized their administration.
• Insurance companies consider these treatments experimental not covered procedures
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A few take home points
• Stem cell therapy is still relatively uncommon
• PRP is being performed in the office for:
– Knee, hip and shoulder osteoarthritis
– Tennis or golfers elbow
– RTC tendinitis
– Patellar tendinitis (jumper’s knee)
– Achilles tendinitis
– Plantar fasciitis
– Ligament sprains
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In Conclusion
• You will be hearing more and more about regenerative medicine therapy
• Appear to be safe (especially PRP)
• Will have an increasing role in treating acute and chronic orthopedic conditions
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