Stem Cells To The Rescue: Relieving Throbbing Joint Pain

Stem Cells To The Rescue: Relieving Throbbing Joint Pain

CREATED Jul 19, 2013

ATLANTA, Ga. (Ivanhoe Newswire) - Fifty million Americans suffer from arthritis. That number is expected to grow to 67 million in the next 15 years.  The pain is becoming so excruciating that record numbers are opting for hip, shoulder, and knee replacements.  However, now you don't have to go under the knife to find relief.

Former State Representative John Lunsford gave speeches, shook hands, and pounded the pavement for eleven years in Georgia.  It all took a toll on his body.

"I was taking about 16 ibuprofen a day and sometimes I'd take two naproxen in the morning and two at night," John Lunsford told Ivanhoe.

Lunsford was suffering from osteoarthritis. Doctors said his only solution was surgery.

"The first one told me I would need a total hip replacement. So, I went to get a second opinion, and he told me I needed a total hip replacement," John said.

Then, he found the next evolution in regenerative medicine, using stem cells to target inflammatory and pain pathways.

"They change the pain pathway so it's no longer as painful. They change the inflammatory pathways in that you don't have as much inflammation being produced and in turn not as much pain," R. Amadeus Mason, MD, Assistant Professor of Orthopaedics at Emory Sports Medicine Center, told Ivanhoe.

Emory Orthopedic Specialists take the stem cells from a patient's own bone marrow, process them, and inject them back into the patients' joint, causing the pain to go away.

"We have also seen regeneration of cartilage," Dr. Mason said.

Patients are able to walk or drive immediately after the procedure and should experience significant overall improvement within six weeks.

"The implant was a little intense for a few seconds, nothing you couldn't deal with.  It was a whole lot less painful than a root canal," Lunsford said.

Out of 50 patients, only one needed surgery.

"We basically turbo charged that site to heal itself and so far so good," Lunsford said.

Stem cell injections are being used mainly in the larger joints: knees, hips, and shoulders. However, because this treatment is so new, doctors don't know how long it will last. After three to four years patients will need to have another injection, or the replacement surgery, and because of that most health insurance plans will not cover it.

RESEARCH SUMMARY

BACKGROUND:  Osteoarthritis is the most common type of arthritis.  It affects an estimated 27 million Americans.  Most people over the age of 60 have it to some degree, but its severity varies.  However, people in their 20s and 30s can get osteoarthritis.  In people over 50, more women than men have osteoarthritis.  It is associated with the breakdown of cartilage in joints and can occur in almost any joint in the body.  It occurs more often in the weight bearing joints of the hips, knees, and spine.  It can also affect the thumb, fingers, neck, and large toe.  Osteoarthritis causes the cartilage in a joint to become stiff and lose its elasticity, making it more susceptible to damage.  (Source: www.webmd.com)

SYMPTOMS/RISK FACTORS: Symptoms of osteoarthritis most often develops gradually and includes:

  • Pain after overuse or after long periods of inactivity
  • Stiffness after periods of rest
  • Bony enlargements in the middle and end joints of the fingers
  • Joint aching and soreness, especially with movement
  • Joint swelling 

There are several factors that increase a person's chances of having osteoarthritis.  They include heredity, obesity, injury, other diseases, and joint overuse.  (Source: www.webmd.com)

TREATMENT:  The condition is usually treated with a number of treatments including weight loss, medications, physical therapy with muscle strengthening exercises, hot and cold compresses to the painful joint, removal of joint fluid, exercise, injection of medications to the joint, and use of supportive devices like canes or crutches.  Surgery is also helpful to relieve pain when other treatment options have not been effective.  The type of treatment depends on several different circumstances, like age, activities, overall health, occupation, medical history, location of disease, and severity of osteoarthritis.  (Source: www.webmd.com)

NEW TECHNOLOGY:  Researchers at Emory Sports Medicine Center are using stem cells to relieve joint pain.  The two places in the body with an abundance of stem cells are the bone marrow (BMAC) and the adipose tissue (fat cells).  These are the two places the doctor may choose to harvest to help treat joint pain or chronic tendon pain.  Stem cells harness the healing power of a patient's own blood and works to actually repair the damaged tissue.  They are isolated from a small sample of a patient's own bone marrow or fat cells and inject them directly into the damaged area.  Emory physicians also use Platelet-Rich Plasma (PRP), which assists in the repair process.  Each patient's treatment plan varies, but the typical patient requires one stem cell injection and a follow-up injection of PRP four to six weeks after the first injection.  Since the cells come from the patient, there is not a chance of their body rejecting it.  At the injection site, there is a very small risk of infection and a chance that some bruising will occur.  (Source:  http://www.emoryhealthcare.org/sports-medicine/pdf/emoryorthostemcell.pdf)

INTERVIEW

Amadeus Mason, MD, Assistant Professor of Orthopedics at the Emory Sports Medicine Center, talks about how stem cells are helping people with joint damage avoid surgery.

How long have you been working with people with joint pain? 

Dr. Mason: I have been working with people with join pain for about 10 to 15 years.

How long have you been working with stem cells? 

Dr. Mason: I have been working with stem cells and for the past four to five years. 

So, what is different about the stem cells? What does it give you that anything else does not? 

Dr. Mason: The stem cell gives us the ability to treat chronic issues without doing surgery. It allows us to offer treatments for people who are not ready for surgery or are not surgical candidates and give them some pain relief and better quality of life.

Could this completely put off surgery for some people forever? 

Dr. Mason: No, not forever. Stem cells usually work for 3 to 4 years ideally and then we reevaluate at the end of that time to see if they will have a repeat injection.

When people come in for this, what are they usually? Are they runners or are they tennis players?

Dr. Mason: It varies. In general it is somebody who is fairly active and has some kind of diffuse cartilage damage, usually in the knee but sometimes in the hip or other joints. They are either too young for surgery or they are not the correct medical condition to undergo surgery.

What other joints can you use this for?

Dr. Mason: You can do just about any joint. The knee and the hip have been the most frequently used because they are the most frequently damaged. It's also done in the shoulder, the ankle, the elbow, and the first metacarpal joint; these are probably the second most common joints that we have done stem cells in.

How do the stem cells work? Where do you get the stem cells from?  

Dr. Mason: We harvest the stem cells in the office from the iliac crest, which is just below the back on either the left or the right side.

Is that painful?

Dr. Mason: Actually, it isn't. After we have uses ultrasound to identify the best harvest site on the iliac crest, we anesthetize the superficial skin over this area. We then anesthetize the subcutaneous tissues all along our planned extraction tract. We all the way down to the iliac crests harvest site – this is again done under ultrasound and we make sure to put ample an anesthesia on the cortical bone. Once we have numbed the entire extraction tract all the way down to the cortical bone, we can poke through the bone of the posterior iliac crest painlessly. Some patients do describe a "weird" "tingling" feeling while we are actually harvesting the stem cells but never painful. We have had to stop a couple of procedures because patients became uncomfortable because they could hear us tapping into the bone.  Now, we can give patients an oral sedative that helps them to be more calm while the tapping is taking place.  

Do you think it will ever change?

Dr. Mason: I think this is the next phase in orthopedics, especially in sports medicine where we are trying to get an active person back to their lifestyle. With this treatment we can fill that gap between when chronic injury limits function and when surgery is necessary, since surgery is going to put them down for a long time and frequently is not very effective in these chronic injury cases.  

You take the stem cells and then do you immediately replace it right then or do you have a procedure that you have to do in the lab?

Dr. Mason: We harvest, process and inject the stem cell all the same day. We harvest about 60 mL of stem cells and blood. We put all that into our centrifuge which spins off the unwanted marrow and blood components which concentrates out the stem cells, some platelets

How long does that take? 

Dr. Mason: With set up, numbing and extraction the harvesting process takes about 30-45 minutess.  The concentrating process takes about 15 minutes. From the 60ml of bone marrow  we typically get about 3-6 ml of concentrated stem cells and platelets to inject.. 

What do those stem cells do for that joint? 

Dr. Mason: There are three main things that stem cells do.  First they change the inflammatory pathways so there is less inflammation produced.  Second they change the sensitivity of the pain fibers so there is less sensitivity to pain. Thirdly they stimulate regeneration of the joint synovium, which is the tissue that nourishes the cartilage. By decreasing inflammation, changing pain pathways and increasing then nourishment of the damaged cartilage all decrease the patient's pain.  In the lab, stem cells have also been shown to stimulate growth in cartilage cells – we have not been able to document this re-growth in vivo. We are hoping that soon we'll get the right aliquots and percentages and will be able to see the cartilage regenerate.

A lot of times when talking about stem cells, it is regeneration but this is not necessarily; this is changing nerve pathways. How does that work? 

Dr. Mason: Truthfully, we are not quite sure of the mechanism. What we do know is that the only regeneration that occurs is in the synovium. What we suspect is that the stem cell are repairing damaged nerve endings and this alleviates the pain.. 

Does that have to do with the type of stem cells that you are taking?

Dr. Mason: No, it is not so much the type of stem cell as it is the cell that you are trying to get them to differentiate into. It is a lot more difficult to get them to differentiate into the cartilage cells than it is to get them to differentiate into the cells that control inflammation or those that control the perception of pain.

After you inject the stem cells, how long until the patient feels different? 

Dr. Mason: It varies. Some people will feel the effects within 24 to 48 hours, but we normally say it takes about 6 to 8 weeks for the initial inflammatory regenerative process to run its course. If you are not one of those lucky few who get the initial relief, we give it up to about 6 weeks for it to start taking effect.

What is the success rate on that?

Dr. Mason: The success rate has been fairly good, we have only had one patient who has failed treatment and went on to get a total knee replacement. We do not have a lot of data behind these results as here at Emory we have only 40-50 of these injections.

Would you ever do the stem cell twice?

Dr. Mason: Absolutely, but none of my patients have not gotten that far out, but we would repeat the stem cells if the pain returns. That is the great thing about the stem cells; you can repeat them as many times as you would like to without causing additional damage or degradation to the joint that you are injecting.  

Is there any recovery for the patient?

Dr. Mason: Not really. At most the patient may have some soreness in the back of their hip at the harvest sight. We tell them wait 7 to 10 days to go swimming because we do have to make a small incision on the back to allow us to get down to the bone harvest site. Apart from that there is really no down time, only 24 to 48 hours of making sure that they do not do excessive activity on that joint. If we are talking about weight-bearing joints like the knee or the hip, that is more important than if we are talking about the shoulder or the hand with the first CMC joint. 

Can you tell me about Andrew Young?

Dr. Mason: Ambassador Young was having significant knee pain from osteoarthritis. He had been told that total knee replacement was his only option.  He had seen many of his friends who had gotten knee replacements have a significant decrease in their mental function following the procedure and so he came to us as a patient who was a staunch opponent to having surgery as he did not want to sufer the same fate as his friends. Ambassador Young had done a fair amount of research on stem cells and identified us as a Center that did stem cell injections. His first words to me were "Tell me about stem cells." 

Where was his problem and what was he like?

Dr. Mason: He was, of course, very gracious. His pain was in his knees. He had significant osteoarthritis in both knees and it was limiting the amount of travel and walking that he was able to do; really compromising his lifestyle. He was very frustrated because he had done physical therapy, steroid injections, the lubricating shots; all of the conservative therapy just short of surgery and now everybody was telling him that surgery was his only option if he wanted to get back to his active lifestyle at over 80 years old.

Is that a big commitment for a man like him because you have to be out of commission for so long for recovery?

Dr. Mason: Yes total joint replacement post-surgical rehab is a big time commitment, but that was a minor part of his concern. The bigger issue he had was the possible effects of the anesthesia, drilling into the bone and how those bone fragments could possibly get into the bloodstream and the possible ill effects they could have.

Did you do both of his knees at the same time? 

Dr. Mason: No, we did not. I usually do not do both knees at the same time because, "The patient don't have a leg to stand on" afterwards - no pun intended, We chose the most significant knee and did that initially. We thought we were only going to do one knee but he did so well on that first knee, he wanted to come back within three months and have the other one done.

How is he today?

Dr. Mason: He is doing great. He said the only issue he has is his back. Now that he walks so much, his back is beginning to have some issues so we are trying to work with him on getting that under control.

How far out is he? 

Dr. Mason: He is now almost 2 years out. 

In the profession that you do, what would you say are the worst sports for people over 50? 

Dr. Mason: It is not so much the sport as it is not seeking treatment when you get injured. Having said that, I think the worst sport for people over 50 is probably running in that you when they get an injury they do not pay a lot of attention to the injury, then that injury can progress to cause further damage. When you play tennis, when you play basketball, when you swim, the injury usually impedes your ability to perform that activity so you will seek treatment more quickly.

Have you changed your lifestyle or do you do anything different after you have seen so many people come in here with joint pain?

Dr. Mason: I have; I do not ski. I try to make sure that I am doing the background things like keeping my joints as strong and as healthy as they can be. I have to confess that when I do get an injury, I tend not to follow up the way I tell my patients to follow up, but if things get to the point where they are impeding my ability to do the activities that help to keep me healthy I would consult with one of my partners.


Why don't you ski?

Dr. Mason: Because of the risk for ACL, the risk for tibial plateau fractures, and also I grew up in Jamaica, so I do not like the cold. 

Can you think of anything to add?

Dr. Mason: I think the big thing that you have to differentiate here is that the stem cells we are using are adult stem cells. These are stem cells that are unique to this patient, so the risk for rejection, infection, and all that is out the window. Also, the risk of ethical issues associated with embryonic stem cells are not there because this is the patient's own blood, and that makes it available for Jehovah's Witnesses as well in certain instances because we are not removing or giving them blood products from somebody else.

FOR MORE INFORMATION, PLEASE CONTACT:

Lori Vasquez
Clinical Assistant
Emory Sports Medicine Center
(404) 778-0209
lori.vazquez@emoryhealthcare.org