AAOM Annual Meeting 2013: “Future Directions in Regenerative Medicine”

“Anatomy is to physiology as geography is to history; it describes the theatre of events.”
– Jean Francois Fernel, De Naturali Parte Medicinae Libri Septem, 1592

 

At the 2013 Annual Meeting of the AAOM, there were some compelling lectures on what may possibly become treatments of choice for difficult conditions such as discogenic back pain (back pain originating from a “pinched nerve” or “slipped disk” in the lower back region), and knee arthritis.

Back pain with associated leg pain is a condition that, first of all, can be very difficult to diagnose because there may be overlapping pain patterns, or pain going down the leg from different sources such as muscle, tendon, ligament, facet joint, or what many people are familiar with as a “slipped disk”. This is otherwise known as the intervertebral disk which acts like a shock absorber between the vertebra of the spine. It is located close to the nerve roots as they come out of the spinal cord which can become “impinged” or inflamed by the disk or its material as it degenerates over time, or from injury.

Common treatments for this condition include epidural steroid injections aimed at decreasing the inflammation on the nerve root, or even more aggressively, surgery is performed to decompress the nerve. Both of these treatments have mixed results, therefore, more recent research has focused on restoring a more normal size and functioning of the disk.

Furthermore, in a study on intradiscal injections to essentially prop up or restore the disk back to its normal functioning anatomy (kind of like re-inflating a tire), Yin and Pauza (Pain Med 2009; 10(5):955.abstract) show a greater than 50% reduction in both back and leg pain at 12 weeks in preliminary studies of this type of treatment.  A multi-center, randomized controlled phase III trial is currently underway in the United States, which supports these preliminary findings.

Another speaker, Chris Centeno, MD of Regenexx, presented some “registry data” (a registry is a group of patients followed in time to monitor the effects of a treatment) on stem cell treatment for knee arthritis. While this type of scientific data is limited in its strength in terms of scientific design, patients in the registry reported an almost 60% relief in their knee pain symptoms (www.regenexx.com). An update of this information from the registry is forthcoming this summer according to Dr Centeno. We have better science for platelet rich plasma (PRP) injections for knee arthritis in terms of “controlled trials” as published in:  http://www.arthroscopyjournal.org/article/S0749-8063(11)00523-8/abstract
http://link.springer.com/article/10.1007/s00167-010-1238-6#page-1

So, what does this mean for patients? Regenerative Medicine as a field is coming up with ways to restore more normal structure and function of the anatomy, as opposed to a surgical option such as “cutting it out or fusing it”. If stem cells go the way of PRP in terms of their scientific study, we will be seeing a paradigm shift in our treatment of degenerative conditions.

For more information, please visit: http://www.pursuitsports.us

Physical Therapy vs Surgery for Meniscal Tears

 “I don’t deserve this award, but I have arthritis and I don’t deserve that either.” 
-Jack Benny

Before I dive into the findings of a recent New England Journal of Medicine study and how this connects to what is called “conservative treatment” (ie; non-surgical), here is a brief description of the medical terminology needed to understand the results and how this fits into your own treatment choices.

The two medical terms involved with this study are menisci and arthritis.

• Menisci are C-shaped cartilage structures within the knee joint which act like shock absorbers or cushions between the thigh bone (femur) and the shin bone (tibia). The menisci also provide stability with various motions of the knee including pivoting, twisting and squatting. Surgery for meniscal tears is the most commonly performed orthopedic surgery.
• Meniscectomy is surgically removing the torn part of the meniscus which takes out the “pain generator” and prevents torn pieces from breaking off and causing further injury
• Arthritis is a narrowing of the joint space associated with degeneration of the cartilage and bony structures of a joint.

Now to the findings of the study published in the New England Journal of Medicine, (NEJM, March 19, 2013 – http://www.nejm.org/doi/full/10.1056/NEJMoa1301408 ). This study indicated that physical therapy vs surgery is no different in efficacy for the treatment of meniscal tears among patients with mild to moderate arthritis. In this well designed study, patients with an average age of 56 were randomly assigned to either the conservative treatment group consisting of physical therapy or the surgical group which was treated with a partial meniscectomy. Further results showed that 30% of the patients in the conservative treatment group receiving physical therapy “crossed over” to get surgical treatment within 6 months. At 6 months and 12 months, the conservative treatment group compared to the surgery group indicated no difference on the WOMAC pain and function scales (http://en.wikipedia.org/wiki/WOMAC ).

Furthermore, as cited in my December 2012 blog article: (https://pursuitsports.wordpress.com/2012/12/14/huh-an-introduction-to-making-sense-of-what-your-doctor-is-trying-and-failing-to-tell-you/ ), shoulder MRI’s in the general population of asymptomatic patients show a high proportion of rotator cuff tears. Similarly,  35% of patients older than 50 will have meniscal tears seen on an MRI, and 67% of them will be asymptomatic (this means that patients do not report any painful symptoms). So, it is worth mentioning again the importance of the physical examination to determine if the meniscus truly is the origin of the pain and then correlating these findings with the MRI before considering aggressive or surgical procedures.

So, what does this mean for patients? General recommendations can emphasize non-surgical treatments for meniscal tears first, as long as they do not have mechanical symptoms (ie; locking, catching or giving way). If the patient shows no improvement after non-surgical treatments or has mechanical symptoms, then considering surgical management would be the next step.

Finally, what about regenerative injections to optimize conservative treatments? There is mounting medical evidence that regenerative injections can be helpful in patients with knee arthritis, so why not engage in this non-surgical treatment for meniscal tears? At present, there are no studies in this specific population of patients who have meniscal tears without arthritis, however, I generally tell patients who want to avoid surgery that we can try non-surgical treatments as long as mechanical symptoms (knee joint locking or catching) are not present. In this New England Journal of Medicine article, the study participants will be followed into the future in order to answer the question as to weather surgery on the meniscus leads to a higher risk of arthritis. If this turns out to be so, then it would be another argument to treat these injuries conservatively with physical therapy and regenerative injections.

For more information, please visit: www.pursuitsports.us
 

 

MUSCULOSKELETAL MEDICINE 101: Prolotherapy, Lifestyle & the Body’s Healing Process

“There has never been a great athlete who died not knowing what pain is.” – Bill Bradley

With all integrative medicine techniques, there will be pros and cons backed up by statistics and studies; some that are based on solid scientific methodology, some based on decades of experiential knowledge, and some based on both. Furthermore in all medical disciplines, there are conflicting arguments for or against any given technique, and one can find evidence to support almost every point of view. In addition, consider that there are not-so-hidden agendas for all concerned – insurance companies, lobbyists, health care professionals, hospitals, pharmaceutical companies, and politicians all have something at stake with new medical information. Fair enough. And now with the onset of ask.com, medicine.com, doctors.com, wikipedia.com, and the blogsophere, patients are becoming both highly educated and deeply disillusioned. Is it any wonder that when one doctor recommends a treatment method, a patient’s knee-jerk reaction is to ask for a second opinion?

I naturally have a scientific mind, have been mentored by some of the best doctors around, and have been working in the osteopathic/sports medicine arena since I started medical school in 1998. My commitment is to relay valuable information I have learned to my patients. I want every patient to leave my office with the feeling that they know what their issue is, what the treatment will be, how it works, and what to expect. If a patient wants to know the “why” of a treatment method, I am excited to share a more in-depth conversation. I believe that knowledge is power, and the more patients understand their individual situations, the more successful their treatment results are likely to be.

Let’s start with an overview of prolotherapy – what is it and how does it work for healing pain?

Prolotherapy is a treatment that stimulates the natural production of new connective tissue such as ligaments and tendons by inducing a mild inflammatory reaction in the weakened ligaments and tendons by producing collagen. Proliferation injection therapy, or prolotherapy, uses dextrose and an anesthetic to create a ‘controlled injury’ at the tender part of the body. The idea of this treatment is to stimulate the healing response of the body which is triggered by the injections. Recent discoveries of prolotherapy have shown that this technique is not only able to restore damaged ligaments and tendons, but is able to repair damaged cartilage as well.

Prolotherapy works by exactly the same process that the human body naturally uses to stimulate the body’s healing system, by a process called inflammation. This injection technique causes an inflammatory response which “turns on” the healing process, and the growth of new ligament and tendon tissue is then stimulated. The ligaments and tendons produced after prolotherapy look almost the same as normal tissues except that they are thicker, stronger, and contain fibers of varying thickness. The ligament and tendon tissue, which forms as a result of prolotherapy, is up to 40% thicker and stronger than normal tissue in some cases.

It is important to add here a brief overview of a more traditional treatment approach to musculoskeletal pain – cortisone shots. A cortisone shot contains an anti-inflammatory medicine called corticosteroid medicine. This method has been used to treat injuries such as tennis elbow, overused and weakened tendons and ligaments, and other strains that are not truly inflammatory problems by nature. Although cortisone shots give patients some temporary pain relief, they don’t fundamentally help long-term because the core issue is weakness, not inflammation. For pain induced by non-inflammatory issues, prolotherapy injection techniques help promote healing via strengthening a weak and injured area.

As I have mentioned in previous articles, a DO provides comprehensive health care services; we use traditional medical practices such as drugs and surgery as well as integrative, musculoskeletal medicine methods.

These musculoskeletal methods include:

Musculoskeletal Ultrasound (MSKUS): This type of ultrasound is used for evaluating muscles, tendons, and ligaments associated with various joints. The advantages of using ultrasound include a comparable, if not more accurate diagnosis of soft tissue injury than an MRI, decreased costs, and the ability to perform what we call “dynamic tests” in real-time, at the point-of-service. MSKUS is also used for guiding injection therapies.

Regenerative Injection Techniques (RIT): There are two types of RIT – platelet rich plasma (PRP) and prolotherapy. PRP involves taking the patient’s blood, spinning it down in a centrifuge to separate platelet cells from the rest of the blood, and then injecting the platelet cells that contain growth factors into the injured area to promote healing. Prolotherapy has been described above in detail. Also, keep in mind that working in tandem with one or both of these types of injection therapies, patients often continue to work with their physical therapists to get the most out of their treatments.

Osteopathic Manipulative Medicine (OMM): This is a treatment commonly used for patients who have strained their back either playing sports or at work, or have been involved in a “whiplash” injury from a motor vehicle accident. Also, many people who have sedentary jobs or sit for a long time at a desk develop “knots” in the shoulder blade region. By performing OMM, a procedure designed to mobilize the restricted motion of the joint, a DO helps relieve symptoms which then aid in tapping into the body’s self-healing capabilities. Osteopathic doctors believe the expanded use of OMM reduces reliance on drugs for many patients who suffer from chronic pain.

Lifestyle Changes: A doctor of osteopathy will also encourage patients to examine their lifestyles, diet, exercise regimens, and mental attitudes. They will look at the whole body, not just where it aches. DOs will also make sure that their treatment regimen fits into a patient’s daily life with their personal commitment to recovery. As I have mentioned before, recovery is a two-way street.

So, where do these integrative, state-of-the-art methods come from?

The father of osteopathy is Andrew Taylor Still, who first used the term in 1874. He was trained as a medical doctor and while most doctors of his time focused on treating sick people, Dr Still became fascinated with what supported health in the first place. He was concerned that many common medical treatments did more to harm patients than to help cure their ailments. Dr Still believed there was a way to help the body heal itself and was particularly interested in the role of the musculoskeletal system (the muscles, bones and nerves that make up 60% of our body mass) in promoting health. In fact, the word “osteopathy” comes from the Greek word for “bone.”

Integrative medical approaches such as prolotherapy are making the medical profession at large stand up and take notice. Asking a patient “where does it hurt?” is just one of many ways a doctor contributes to the healing process. Also key are factors such as: how and how much people sleep, what a patient’s sex life is like, what people eat everyday, how much exercise they get, and what kind of jobs they have… all are indicators for doctors to help support a patient’s recovery. In osteopathic medicine, taking into consideration the whole person works to cure ailments and pain. Of course, further medical research will no doubt add to the positive results that my patients are experiencing now. This is cutting edge medicine at its best.

For more information, please visit: http://www.pursuitsports.us