Apr 25, 2016
Last week, a patient presented with intractable right sided knee pain of five days duration following a fall in his home. I evaluated him and found no swelling, no limitation in the range of motion, no tenderness, no instability and no bruising. I caused an X-ray to be taken and it was “negative”. He sat in my office rubbing his painful knee. I remembered that when he first became my patient four years earlier, he had presented for a second opinion pertaining to his knee and had been scheduled at a major medical center for arthroscopy the following week. After my complete assessment at that time, my diagnosis was spinal stenosis and right lumbar radiculitis; that is nerve root irritation in the back at L3-L4 referring to his knee. I arranged for an epidural steroid injection at that time and he has lived without pain for four years until the aggravation of the preexisting spinal arthritic disorder by the fall last week. He was experiencing referred pain to the knee from an arthritic back.
A second patient had presented two weeks ago with a very painful right knee limiting his work and interfering with his activities of daily living. His examination excluded swelling, warmth, tenderness, instability, limitation in the range of motion or a limp. The X-ray of the knee excluded any significant abnormal changes. I referred him for an MRI of his spine and the report came back Friday consistent with a herniated nucleus pulposis (slipped disc) at L3-L4. That latter patient is scheduled later this week for an epidural steroid injection.
The third scenario is equally informative as it involves a colleague at a major medical center in Chicago. He was experiencing calf cramps with severe night pain. Because he concluded the problem was from his leg and ankle, he sought attention from a foot and ankle surgeon who promptly sent him for imaging of his leg. Because of a long-term personal relationship, I recalled that ten years ago, he had had an epidural for radiculitis (referred pain down a leg) having to do with an arthritic low back. I asked him to share his recent MRI and there was the diagnosis “severe stenosis”. Both the physician patient and his foot and ankle specialist had discounted the MRI result because of the absence of back pain.
The lesson to be learned from this Blog is that all symptoms may not necessarily arise from the point of discomfort and you can have disabling extremity pain, no back pain and the source may still be the spine. If your doctor doesn’t know that, teach her or him.
Tags: arthritis, athletes, Benefits and Risk, Interventional Orthopedics, Knee, Knee Pain Relief, Mature Athlete, medicine, Orthopedic Care, Orthopedic Surgeon, Orthopedics, Osteoarthritis, Pain Management, stem cells, treatment
Apr 4, 2016
Patients should participate in strengthening, low-impact aerobic exercises, and neuromuscular education; and engage in physical activity.
Rationale:
This recommendation is rated strong because of seven high-strength studies of which five showed beneficial outcomes. The exercise interventions were predominantly conducted under supervision, most often by a physical therapist.
I recommend weight loss for patients with symptomatic osteoarthritis of the knee and a BMI = 25.
Rationale:
Physical Function shows important improvement in outcomes for this patient population. Function also shows statistical improvement that is clinically significant. Diet and exercise combined achieves the best results.
I do not recommend using acupuncture in patients with symptomatic osteoarthritis of the knee
Rationale:
In Studies that comparing acupuncture to groups receiving non-intervention sham, usual care, or education, the majority, show no clinically significant improvement. While there is a lack of efficacy, there is no potential harm.
I am unable to recommend for or against the use of physical agents (including electrotherapeutic modalities) in patients with symptomatic osteoarthritis of the knee.
Rationale:
Due to the overall scientifically inconsistent findings for various physical agents and electrotherapeutic modalities, I am unable to make a recommendation for or against their use in patients with symptomatic osteoarthritis of the knee. To better understand the role of pulses in the management of arthritis, I am waiting for FDA approval to launch a clinical trial using a pulsed brace after a bone marrow concentrate/stem cell procedure.
I am unable to recommend for or against manual therapy in patients with symptomatic osteoarthritis of the knee.
Rationale:
Due to the lack of studies examining most manual therapy techniques, I am unable to opine. No studies evaluating joint mobilization, joint manipulation, chiropractic therapy, patellar mobilization, or myofascial release were found of scientific merit.
I cannot recommend using glucosamine and chondroitin for patients based on science; yet I personally use them
Rationale:
At this time, both glucosamine and chondroitin sulfate have been extensively studied. There is essentially no evidence that minimum clinically important outcomes have been achieved compared to placebo. There is no evidence of potential harm. The same may be said of the neutraceuticals methylsulfonylmethane, omega-3, gelatin, vitamin D, dimethylsulfoxide, antioxidants, and coenzyme Q10. 01
I will not use needle lavage for patients with symptomatic osteoarthritis of the knee.
Rationale:
The published evidence shows little or no benefit from needle lavage in the treatment of osteoarthritis of the knee.
I am able to recommend growth factors and stem cells derived from Bone Marrow Aspirate in conjunction with platelet rich plasma for patients with symptomatic osteoarthritis of the knee.
Rationale:
I have an ever-increasing Data-Base of Outcome measurements to support my recommendations with Levels of Evidence at 1B and 3 with a Grade D governmental guideline Grading (the highest). You may learn more at the National Guideline Clearinghouse (http://www.guidelines.gov) or make an appointment at 847 390 7666
Tags: arthritis, athletes, Benefits and Risk, bone marrow, Bone Marrow Concentrate, Clinical Trial. Mitchell B. Sheinkop, Concentrated Stem Cell Plasma, Hip Replacement, Interventional Orthopedics, Knee, Knee Pain Relief, Mature Athlete, medicine, Orthopedic Care, Orthopedics, Osteoarthritis, Pain Management, Platelet Rich Plasma, Regenerative, Regenexx, Regenexx-SD, stem cells, treatment
Mar 28, 2016
Cartilage damage may result from trauma, repetitive motion/impact, abrupt abnormal weight bearing, fractures, wear/degeneration, joint infection, meniscectomy, friction/abrasion due to abnormal joint alignment, inflammatory diseases or a genetic predisposition to name a few reasons. The primary symptoms are pain, loss of motion and functional impairment.
As a form of connective tissue that is very primitive from an evolutionary standpoint, cartilage does not lend itself to intrinsic repair. All the attributes required for healing, while present in bone, are missing in cartilage including blood vessel supply, pain fibers, regenerative cells, fluid balance, and a rich source of nutrition. The cartilage in your joint is not populated by metabolically active cells nor is the chondrocyte capable of positively influencing its own environment. In keeping with all of the principal shortcomings of cartilage, chondrocytes do not replicate after age 40 and cannot migrate.
Because articular cartilage damage from any of the aforementioned causes is permanent and progressive, it is paramount that intervention takes place early in the degenerative process or soon after injury. The likelihood of a successful, enduring repair or restoration diminishes as generalized cartilage deterioration progresses.
There are many palliative interventions available such as weight loss, non-steroidal anti-inflammatory medication, shoe wedges, off-loader braces, cortisone injections, gels/visco-supplementation, and most recently, amniotic fluid concentrates. Missing though from all of these options is the regenerative potential. Bone Marrow Aspirate Concentrate not only introduces regenerative potential via adult mesenchymal stem cells, it is a huge resource for anti-inflammatory molecules termed cytokines. Equally important though are the extracellular vesicles (exosomes) termed growth factors. What about adipose derived stem cells and cultured stem cells?
While adipose tissue contains stem cells, the latter are not available unless liberated from their surroundings. An enzyme, collagenase has been the necessary ingredient but the use of collagenase is interpreted as tissue manipulation and thus not allowed by the FDA. While there was an introduction last July of a mechanical means of liberating stem cells from fat graft harvest, there are no outcomes as of yet to support said alternative. At the same time, while adipose derived stem cells have been used outside of the US, there are no studies indicating better outcomes with adipose derived cells as compared to bone marrow derived stem cells. The remaining question at this time is whether the results of cultured stem cells are superior to Regenexx SD outcomes. While there is anecdote, we have no Evidence Based Information to help guide Clinical Appropriate Use Criteria.
With all the above written, I am done for today; if you are still unclear or uncertain, call the office for an appointment.
847 390 7666
Tags: Amniotic, arthritis, athletes, Benefits and Risk, bone marrow, Bone Marrow Concentrate, Clinical Studies, FDA, Interventional Orthopedics, joint replacement, Knee, Knee Pain Relief, medicine, Orthopedic Care, Orthopedics, Osteoarthritis, Pilot Study, Regenerative, Regenexx, Regenexx-SD, stem cells, treatment
Mar 3, 2016
I haven’t yet heard or read the Thursday Mitt Romney speech as I write this Blog, but as long as the terms Fraud, False Promises, Uninformed, etc. will be headline news this afternoon and all over television tonight, I thought I would expand the theme to which I read and see about misrepresentation when it comes to Cellular Orthopedics. When my computer fired up this morning, one of the first bullets advertised an international stem cell company offering Exosomes if you travel outside of the United States for care. For those of you unfamiliar with the term, Exosomes are extracellular vesicles that have the potential to do good things to your cartilage and soft tissues. As I read the stem cell ad, I noted the following:
“Exosome Injection is a human induced pluripotent stem cell-derived mesenchymal stem cell treatment, which has emerged as a promising supplement to stem cell transplantation therapies. Exosomes derived from mesenchymal stem cells can play an important role in repairing injured tissues. Exosome injection is also utilized as a complement to bone marrow stem cell extractions.”
Thank goodness for the FDA. While the governmental agency has been frequently criticized, the FDA is there to protect us; that’s why you have to travel outside the US for unproven “promising” interventions. To continue the “promising” discussion, the web site promoting Exosomes also invites you to travel outside of the United Sates for Stem Cell assistance with Cancer, Parkinson’s Disease, Alzheimer’s, Cerebral Palsy, etc. 60 Minutes, we need you.
There is a better option to help avoid or postpone a joint replacement, diminish pain, increase motion and improve your functional capacity. At the same time it falls under the standard of practice and thus is FDA compliant; namely the Bone Marrow Aspirate Concentrate/ Stem Cell approach. Not only does Bone Marrow contain Adult Mesenchymal Stem Cells, anti-inflammatory molecules termed, as a group, Cytokines, as well as multiple cellular molecular secretions called Growth Factors; you guessed it, Bone Marrow Concentrate is a great source of those extra cellular vesicles, Exosomes. My Regenexx affiliation and the International Orthopedics Foundation offer quality assurance and safety in an otherwise poorly regulated environment. While the FDA had an April meeting scheduled for testimony and Regenerative Medicine review; that meeting is now set back six months because of a change in leadership at the FDA. Until that delayed meeting, for quality assurance and evidence based cellular orthopedics, seek what is safe, what has been shown to work and forget about “promising supplements.”
Tags: arthritis, athletes, Benefits and Risk, bone marrow, Bone Marrow Concentrate, Clinical Studies, FDA, Interventional Orthopedics, Knee, Knee Pain Relief, Mature Athlete, medicine, Orthopedic Care, Orthopedic Surgeon, Orthopedics, Osteoarthritis, Pain Management, Regenerative, Regenexx, stem cells, treatment
Feb 22, 2016
While skiing last week in Vail, Colorado, I had the opportunity to sit down with Mitchell Sheinkop, MD, Fellow of the American Academy of Orthopedic Surgery and Fellow of the American College of Surgeons, to learn about the emerging field of Interventional Orthopedics. In 2007, Dr Sheinkop received the Shaare Zedek International Humanitarian Award in recognition of his global orthopedic educational endeavors.
Question: Do stem cells really work?
Answer: There is a misconception regarding joint restoration as it is not the adult mesenchymal stem cell alone that is responsible for postponing or even avoiding a joint replacement in the arthritic setting.
Question: All I read and hear about are stem cells?
Answer: Unfortunately, ad placement hype is competing with good science for the patient’s attention and owing to advertising and marketing; the real message may be getting lost.
Question: Would you please explain?
Answer: When I “graduated” from a knife to a needle, I too believed that it was the stem cell that would morph into cartilage. We now know that the Adult Mesenchymal Stem cell orchestrates the regenerative process and directs other cells and molecules to help reverse the arthritic process, effect healing and improve function.
Question: Who are the members of the orchestra, so to speak?
Answer: When injury occurs, platelets aggregate to initiate the healing process. The activated platelet recruits the cells lining capillaries (pericytes) that then function as stem cells. Control of the bio-immune response and the regeneration affected by anti-inflammatory molecules termed Cytokines and cellular secretions known as Growth Factors are directed by the stem cell.
Question: Where do all of these stem cells, cytokines and growth factors come from?
Answer: When it comes to the musculoskeletal system, we look to the patient’s own Bone Marrow Aspirate Concentrate as the only FDA tolerated resource .While you may be aware of the potential of adipose tissue as a stem cell resource, in order to liberate the stem cell, fat has to be digested with an enzyme, collagenase. As of this interview, enzymatic digestion is not approved by the FDA nor are there significant scientific studies to support adipose derived stem cells for arthritis.
Question: I am aware of plastic surgeons offering fat graft for arthritis, is it effective and legal?
Answer: Neither but it is expensive. Fat graft is not a source of regeneration; it is filler for cosmetic surgery.
Question: I am aware of a media blitz promoting Amniotic Fluid Concentrate as a source of stem cells?
Answer: The research at the Interventional Orthopedic Foundation demonstrated that while there are stem cells in amniotic fluid along with Hyaluronic acid, anti-inflammatory Cytokines, and Growth Factors when that fluid is harvested in conjunction with a Cesarean section; after processing, freezing and the quick thaw, there are few if any viable stem cells remaining.
Last Question: How might a patient seeking to manage arthritis without surgery make the right therapeutic decision?
Answer: Just as our presidential campaigns, paraphrasing Dahleen Glanton in the Chicago Tribune, Monday, February 22, are a cesspool of empty promises and lies, so too is the marketing of stem cells; witness the advertisement featuring a chiropractic spokesperson in The Chicago Tribune, Tuesday, February 9, 2016, placed by The Stem cell Institute of America.
When you seek a Regenerative Medicine consultation, make sure that physician is fellowship trained, board certified and integrates clinical research with his or her practice. Don’t depend on anecdote; inquire about outcomes data. In my practice as well as in those other members of the Regenexx Network, we base our clinical decisions and therapeutic recommendations for Cellular Orthopedics on Documented Results.
Mitchell Sheinkop, MD accepted Emeritus Professor status as the director of the joint replacement program at Rush University Medical Center six years ago where he had played a major role over 37 years in the development of the department of orthopedics and in the founding and growth of Midwest Orthopedics. Since that time he has played a major role in the emerging field of Interventional Orthopedics.
Tags: arthritis, athletes, bone marrow, Bone Marrow Concentrate, Clinical Studies, Hip Replacement, Interventional Orthopedics, joint replacement, Knee, Knee Pain Relief, Mature Athlete, medicine, Orthopedic Care, Orthopedic Surgeon, Osteoarthritis, Pain Management, Regenerative, Regenexx, Regenexx-SD, stem cells, treatment
