Archive for category Osteoarthritis
Hand Surgery Alternative for Arthritis and Injury
Posted by Mitchell B. Sheinkop, M.D. in Hand, Osteoarthritis on February 21, 2012
I have recently seen an increasing number of patients with altered function of their hands because of pain or reduced range of motion due to common injuries, overuse, basal joint arthritis/osteoarthritis, or other degenerative problems.
Thumb arthritis (or basal joint arthritis) can appear early in life. Because of the constant swiveling and pivoting motions of the basal joint–the joint at the base of the thumb, or thumb CMC (carpometacarpal) joint–the thumb joint tends to wear out easily. Basal joint arthritis is also common in people who have osteoarthritis. As well, tendinitis in the wrist and hand is rampant because of over use of the computer mouse and improper ergonomics.
One way to treat the arthritic condition is with total joint reconstruction surgery. Perhaps over use syndromes may be reduced via voice recognition software but I personally still need to edit and then correct about 15% of my dictations. While surgery may improve the condition for some, this is not the case for all. New problems in the thumb joint may redevelop over time, causing such symptoms as numbness or tenderness. Then there is amazing increase in the occurrence of trigger finger and De Quervains Disease; both which lend themselves to ultrasound guided injection.
A reasonably successful approach to all of these wrist and hand problems is to start with an ultrasound guided intraarticular cortisone injection. Should the latter be of short-term relief, then platelet rich plasma may be successful for a longer period. Before considering the surgical alternative, be aware that Regenexx has published the outcome of 6 patients who were just under a year out (11.3 months) from treatment with their own stem cells 83.4% of thumb patients are reporting greater than 50% improvement after a simple injection of their own stem cells, 66.7% of thumb patients are reporting greater than 75% improvement and the average change is 70% improved. No significant complications in this group were reported.
If you have pain in your hand or wrist, start with a change in the ergonomics in your work place. Most office suppliers have the necessary mechanical devices available. The next step is an arthritic glove available in most large drug stores. If unsuccessful, the next step is an ultrasound guided injection of cortisone, platelet rich plasma and then stem cells in that order when all else fails.
Mitchell B. Sheinkop, M.D.
847-390-7666
1565 N. LaSalle Street, Chicago, Illinois 60622
An experimental treatment offered for sale is not the same as a clinical trial.
Posted by Mitchell B. Sheinkop, M.D. in knee, Osteoarthritis, Platelet Rich Plasma, Regenerative Pain Center, Stem Cells on February 6, 2012
Musculoskeletal Care of the Mature Athlete
As I move closer to actually starting up the Bone Marrow Concentrate Stem Cell Pilot Study, I will continue to educate the perspective patient seeking to enjoy relief from arthritis of the hip and knee without a joint replacement. The delay is based on our having to wait for Institutional Review Board approval of our clinical trial. The fact that a procedure is experimental does not automatically mean that it is part of a research study or clinical trial. A responsible clinical trial can be characterized by a number of key features. There is preclinical data supporting that the treatment being tested is likely to be safe and effective. Before starting, there is oversight by an independent group such as an Institutional Review Board or medical ethics committee that protect patients’ rights, and in many countries the trial is assessed and approved by a national regulatory agency, such as the European Medicines Agency (EMA) or the U.S. Food and Drug Administration (FDA). The study itself is designed to answer specific questions about a new treatment or a new way of using current treatments, often with a control group to which the group of people receiving the new treatment is compared. While historically, the cost of the new treatment and trial monitoring is defrayed by the company developing the treatment or by local or national government funding; to date that has not occurred with stem cell trials in the United States. It takes an average of seven years and $750,000,000 to develop a new pharmaceutical therapy. With the rapidity in evolution of regenerative medicine, so far, no company has been identified that is willing to underwrite the expenses of a stem cell Trial. At the same time, beware of expensive treatments that have not passed successfully through clinical trials.
Responsibly conducted clinical trials are critical to the development of new treatments as they allow us to learn whether these treatments are safe and effective. I believe there is enough clinical experience to support a Pilot Study with Adult, Autogenous, Bone Marrow Derived Stem Cells. First no harm and a then reasonable chance of restoring function. To find out if you would qualify for the Pilot Study, contact Jennifer at 312-475-1893 ext.15
FDA Warning on Stem Cells
Posted by Mitchell B. Sheinkop, M.D. in Osteoarthritis, Regenerative Pain Center, Stem Cells on January 12, 2012
Because of the 60 Minute Television program exposing fraud in the marketing of Stem Cells last Sunday, I feel it necessary to preempt the previously announced blog for this week with a word or more of caution. Sometimes called the body’s “master cells,” stem cells are the precursor cells that develop into blood, brain, bones and all of your organs. When used as a medical treatment, there is the potential to repair, restore, replace and regenerate cells and thereby treat many medical conditions and diseases including arthritis.
But the Food and Drug Administration (FDA) is concerned that the hope, which patients have for cures not yet available, may leave them vulnerable to unscrupulous providers of stem cell treatments that are illegal and potentially harmful. Witness the Sunday night episode of 60 Minutes.
FDA cautions consumers to make sure that any stem cell treatment they are considering has been approved by FDA or is being studied under a clinical investigation that has been submitted to and allowed to proceed by FDA.
Regulation of Stem Cells
FDA regulates stem cells in the U.S. to ensure that they are safe and effective for their intended use.
Stem Cells that come from bone marrow or blood are routinely used in transplant procedures to treat patients with cancer and other disorders of the blood and immune system.
Why my Pilot Study and then Clinical Trial? As part of these studies, I must show how the product will be harvested and prepared so that FDA can make certain appropriate steps are being taken to help assure the product’s safety, purity and potency.
Consumers need to be aware that at present—other than cord blood for certain specified indications—there are no approved stem cell products.
Advice for Consumers
- If you are considering stem cell treatment in the U.S., ask your physician if the necessary FDA approval has been obtained or if you will be part of an FDA-regulated clinical study. This also applies if the stem cells are your own. Even if the cells are yours, there are safety risks, including risks introduced when the cells are manipulated after removal.“There is a potential safety risk when you put cells in an area where they are not performing the same biological function as they were when in their original location in the body. Cells in a different environment may multiply, form tumors, or may leave the site you put them in and migrate somewhere else.
- If you are considering having stem cell treatment in another country, learn all you can about regulations covering the products in that country. Exercise caution before undergoing treatment with a stem cell-based product in a country that—unlike the U.S.—may not require clinical studies designed to demonstrate that the product is safe and effective. FDA does not regulate stem cell treatments used solely in countries other than the United States and typically has little information about foreign establishments or their stem cell products. China has recently announced a governmental mandated regulation of a prior free for all in the stem cell market.
- To reemphasize my approach to realizing the promise of stem cell management of arthritis; treatment at the Regenerative Pain Center will only be offered via Pilot Study or Clinical Trial under FDA governance and IRB regulation. Your cells will be harvested from your own bone marrow, concentrated, and administered to your arthritic joint.
Mitchell B. Sheinkop, M.D.
1565 N. LaSalle Street
Chicago, Illinois 60610
847-390-7666
Bone on Bone
Posted by Mitchell B. Sheinkop, M.D. in Osteoarthritis on September 20, 2011
Musculoskeletal Care of the Mature Patient
The use of the phrase “I have Bone on Bone” by new patients in my office setting is dramatically increasing. These are people who are seeking second opinions and consultations as to whether to proceed to surgery or try Platelet Rich Plasma or even stem cell management first. My standard of practice each and every time I see a patient is to perform a historical medical review and a physical examination. I am still amazed at how many patients think they need a procedure when they are really experiencing the symptoms of referred pain from spinal stenosis or degenerative disc disease. If the patient has full and a symmetrical range of motion at the hip and knee, more probably than not the pain is referred in nature even if the X-ray is interpreted as “bone on bone”. If an intra-articular local anesthetic/cortisone “cocktail’ doesn’t relive the pain, I address the spine.
“Perception is everything; and new technologies lead to new concepts. Osteoarthritis is common and not necessarily a progressive disorder, with the condition stabilizing in most cases. This is obvious if we compare the number of people in the population with radiographic evidence of OA and the number who come to joint replacement. Recent research has indicated that physical activity optimizes cartilage health and is important in preventing the symptoms even in the presence of radiologic evidence of osteoarthritis.” The quotation is lifted from my blog of September 13.
A joint is an anatomical approximation of two bones separated by hyaline cartilage. That cartilage serves as a gliding surface. In the knee, there is a second form of cartilage, the meniscus. The meniscus distributes forces and stabilizes. Cartilage basically has no blood supply. The loss of the joint space on an X-ray suggests the loss of cartilage but only from a qualitative sense. The X-ray and even a standard MRI doesn’t allow for quantitative measurement of any remaining cartilage. That cartilage may have diminished in its integrity because of remote trauma, genetic factors, developmental and acquired conditions, obesity, predisposing diseases, chronic inflammation and autoimmune co-morbidities, etc. While Platelet Rich Plasma and Stem Cells are not going to cause re-growth of cartilage in a 55 year old plus individual, case studies from select sites around the world to relieve pain and restore function thereby avoiding surgery are compatible with outcomes sufficiently satisfactory to cause me to continue my initiative for bringing a clinical trial with stem cell treatment for arthritis to the Chicago. Not a shot and a fee but a scientific study of clinical outcomes under IDE auspices.
Mitchell B. Sheinkop, M.D.
847-390-7666
1565 N. LaSalle Street, Chicago, Illinois 60610
Arthritis and Athletics
Posted by Mitchell B. Sheinkop, M.D. in Osteoarthritis on July 26, 2011
On Sunday, after my morning 30 mile bike ride-in just under two hours (no hills but lightening and thunder))-, I watched the last stage of the Tour De France. Later in the day, my wife gave me an article she had cut out of the July 11, 2011, Chicago Tribune, “Pitcher with artificial joint wants shot at the majors” by Bob Young. It calls to mind the ongoing lack of consensus concerning restrictions after an artificial joint and why I am so interested in the rejuvenative potential of Platelet Rich Plasma and Mesenchymal Stem Cells.
While there is an abundance of research on the throwing arm of a pitcher, there is little data on the forces across the hip during the pitching cycle. Young described in the Tribune article, the drive behind 25-year-old Isaac Hess and his quest to pitch in the majors even though at 20, he had undergone a total hip replacement for an arthritic condition. I was reminded of Bo Jackson, whose major league career ended about six months after a total hip replacement and the multiple revision surgeries that followed. Because of my personal interest in cycling, I do know something about forces across the knee. The following summarizes research in which I have been very involved.
KNEE JOINT BIOMECHANICS DURING CYCLING IN PATIENTS WITH TOTAL KNEE ARTHROPLASTY
Cycling is a recommended activity after total knee arthroplasty (TKA) and it has been shown that up to 50 % of the TKA patients ride a bike and 25 % think that cycling has an important place in their life. Our studies investigated the contact pressures in TKA components for common recreational activities (cycling, power walking, downhill walking, jogging and concluded that cycling produces relatively low contact forces and
therefore is a safe activity for TKA patients.
In order to investigate the kinetic conditions under which the knee was functioning, three-dimensional pedal forces were recorded. The force measurement system was integrated into the crankshafts and was based on strain gage technology. Forces were calculated in a global coordinate system and the impulse introduced to each leg was determined. Motion analysis was performed using a technique called “point cluster technique” Twenty-one reflective markers were placed on the thigh and shank creating two cluster groups. Marker motion was observed with a four-camera optoelectronic system. Subjects were instructed to cycle at a self-selected speed at a preset resistance. Based on the determined eigen values the rigid body motion of thigh and shank was calculated and the relative joint motion was computed.
RESULTS: Resultant pedal forces and generated impulse showed no significant differences between TKA patients and Normals. No significant differences for force and impulse values were found comparing left/right, dominant/non-dominant and operated/nonoperated knee. Patients with contra-lateral osteoarthritis (OA), as defined by the clinical examination and the knee society score, showed higher forces and impulses at the operated leg.
DISCUSSION: Interestingly, in this study, force and impulse of TKA patients with contemporary prostheses were comparable to healthy subjects indicating functional restoration of the joint. Contra lateral osteoarthritis may cause higher forces at the operated leg and thus, relatively higher stresses at the artificial articulation.
As expected, the generated forces at the bike pedal were low (20 – 25% body-weight) calling for little muscle activity and low compressive joint forces.
Treating knee arthritis via joint preservation and regeneration
Posted by Mitchell B. Sheinkop, M.D. in knee, Osteoarthritis, Regenerative Pain Center on June 21, 2011
Musculoskeletal Care of the Mature Patient
There is a very unique challenge concerning how to manage the effects of aging and its impact on musculoskeletal well-being and continued participation in sports-from the weekend to the master athlete. As the majority of patients I see come for impairment of the knee, that will be the subject of this Blog. No matter which joint though, the major problem as we age is weight gain despite a high level of activity and the same nutritional patterns as when we were younger. One must be aware that the body’s Resting Metabolic Rate (RMR) comprises 60-75% of daily energy expenditure and that RMR decreases 20% from childhood to retirement. So too, just as there is a tendency to gain weight, there also is the reality of continued loss of muscle mass with aging. Even if your weight remains unchanged, your percent body fat will increase. If you don’t believe me, take your clothes off and look in the mirror. To make matters worse, joint cartilage doesn’t physiologically reproduce after age 40, so whether it be genetically programmed or from injury, the cartilage loss is historically irreversible.
All bad news so far about athletics with aging but the vicious cycle can be broken. First of all, try to be as thin as possible while still maintaining good health. Second, you need to strength train in addition to aerobic and anaerobic conditioning. That’s where cross training is exceedingly helpful. When your knee hurts, water based exercising is the fix. When you can’t run, biking is the approach. From my perspective, when the over the counter analgesics and anti-inflammatories aren’t affective, the first line of approach is an intra-articular cortisone injection coupled with a prescription for an anti-inflammatory and physical therapy. Bracing is beneficial starting with an over the counter support. Also consider an orthotic in your shoe to level your running and walking and thereby correct force transmission to the knee. The next step in magnitude for the arthritic knee is the unloading brace (orthotic) with or without the electro-stim adjunct. If the intra-articular cortisone injection benefit lasts four months, it may be repeated a total of three times in a year. If not, visco-supplementation is the next option. This injection of hyaluronic acid has proven very helpful in managing knee arthritis. The latter series of injections may be repeated twice a year at six-month intervals. While five years ago, the visco-supplementation series required up to five injections per series, now the demand is one to three visits owing to advances in science.
OK, you have done all these things and the pain and impairment relief are no longer affective, now what? Platelet Rich Plasma is the latest and maybe the greatest; we shall see. My colleagues and I are using PRP with early very positive early results. Caution, up until the usage of Platelet Rich Plasma, treatments were covered by private indemnification and Medicare either all or in part. PRP is an out of pocket expense. Naturally, the final step before a joint replacement will be stem cell based and we’re working toward that end. If you can’t wait, have a total knee replacement; there are inherent risks that are permanent so be a well-informed consumer. If you are able to wait, take my prescription and follow the algorithm for TREATING KNEE ARTHRITIS VIA JOINT PRESERVATION AND REGENERATION.
Injection of Platelet-Rich Plasma in Patients with Primary and Secondary Knee Osteoarthritis: A Pilot Study
Posted by Mitchell B. Sheinkop, M.D. in Osteoarthritis, Platelet Rich Plasma, Uncategorized on April 12, 2011
Musculoskeletal Care of the Mature Patient
In an attempt to evaluate the clinical effects of harvesting platelets from the blood, concentrating them and injecting the concentrate, platelet-rich plasma (PRP), in to the knee joint of patients with primary and secondary osteoarthritis, a single-center, uncontrolled, prospective preliminary study was undertaken. The scientific theory behind the study was based on the fact that most of the current treatments for osteoarthritis are palliative and attack symptoms rather than influence the biochemical environment of the joint. Autologous platelet-rich plasma not only releases growth factors, it promotes concentrated anti-inflammatory signals including interleukin-1ra, the latter being a focus of emerging treatments for osteoarthritis.
In the study, 14 patients with primary or secondary knee osteoarthritis who met the study criteria received three platelet-rich plasma injections in the affected knee at 4-week intervals. Outcome measures included the Visual Analog Scale, Activities and Expectations score and Knee Injury and Osteoarthritis Outcome Score at two, five, 11,18, and 52-week follow-up visits.
The Study, first and foremost, did not result in any adverse or harmful events. What was observed were significant and almost linear improvements in all the scores measured. One could conclude that platelet-rich plasma is safe and potentially could postpone or eliminate a patient’s need for a total knee replacement. At present, there are few options for patients with mild to moderate arthritis to alter disease progression. While both arthritis and joint pain become more common with age, they’re by no means inevitable. There is a long list of modifiable risk factors-obesity, injury and overuse, infections, and on-the-job squatting and kneeling. The current practice is relief at the pharmacy. The study described was done at the Orthohealing Center in Los Angeles and used a non-surgical healing treatment being applied in many fields, including plastic surgery, cardiothoracic surgery, and dentistry. In orthopedics, PRP has been used for tendinopathies and soft tissue injury. Platelet-Rich Plasma injections are potentially very cost effective by reducing the need for pharmaceutical and surgical management while targeting the biochemical process of osteoarthritis. The next step is testing highly concentrated platelet rich plasma and that should be available in my office starting next week.
