The Orthobiologic Institute (TOBI) Faculty Kenneth Mautner Publishes Study in the Journal of American Academy of Physical Medicine and Rehabilitation:
Kenneth Mautner, The Orthobiologic Institute (TOBI) Faculty, recently published a new article in the Journal of the American Academy of Physical Medicine and Rehabilitation titled Where Do Injectable Stem Cell Treatments Apply in Treatment of Muscle, Tendon, and Ligament Injuries? The study examined current treatment options for muscle, tendon, and ligament injuries; including cortisone injections, prolotherapy, percutaneous needle tenotomy, platelet-rich plasma (PRP), and stem cell applications.
The paper outlines each treatment modality beginning with corticosteroid injections, which are currently the most widely used modality for muscle, tendon, and ligament injury. Corticosteroids have proven to provide acute relief of pain, but many RCTs have shown reversal of this relief at intermediate and long term follow up. In addition, corticosteroids may reduce tendon strength and collagen synthesis in injected tissues.
Prolotherapy employs an irritant solution along with needling of soft tissues to stimulate a low-grade inflammatory reaction that works to initiate a healing cascade in the injured tissue. Its use dates back to the 1930s and many uncontrolled trials have shown effectiveness in the treatment of a wide range of musculoskeletal pain and chronic soft tissue injuries.
The role of PRP in sports medicine has continued to grow over the past decade. PRP contains elevated platelet concentrations along with key signal proteins, growth factors, chemokines, and cytokines that work to initiate and regulate the inflammatory cascade. High platelet concentrations are known to stimulate proliferation and differentiation of mesenchymal stem cells (MSCs) at the site of injury. Due to varied and conflicting research on the efficacy of PRP compared to placebo, further research is needed to determine the optimal use of PRP in acute or chronic soft tissue injuries.
Stem cells exist in an undifferentiated or unspecialized state and provide the capability to directly deliver progenitor cells to the area of damage. The available injectable stem cell therapies include MSCs, tenocyte-derived stem cells, adipose-derived stem cells, amniotic-derived stem cells, and dermal fibroblasts; of these the most well studied modality are MSCs derived from bone marrow and adipose-derived stem cells. Considerations for these stem cells include ease of acquisition, autologous versus allogenic source, availability and concentration, lineage differentiation ability, morbidity to the donor site, and need for culturing post-harvest. There is still much research needed to elucidate the full efficacy and use of this treatment modality.
In addition, Mautner outlines the basic pathophysiology of tendon, muscle, and ligament disease; which generally occur when forces overwhelm the structural strength of the tissue. After injury, an inflammation cascade is integral in the natural healing process of the tissue, and he states,
“success of healing is measured histopathologically by the composition of the remodeled structural framework and clinically by the resolution of pain and the return of normal strength, range of motion, and function.”
Although strict FDA regulation of stem cell acquisition and expansion has led to a dearth of clinical research of stem cell treatment for soft tissue injuries, a number of studies based in the United Kingdom have shown favorable outcomes with stem cell injection for refractory lateral epicondylitis, with decreased number of tears, new vessels, and tendon thickness seen on follow up ultrasound. A prospective RCT performed ultrasound-guided autologous skin-derived stem cell injection for patellar tendonopathies; and “compared to a control group injected with autologous plasma only the stem cell group had statistically significant and faster improvement in pain and reduced functional disability as measured up to 6 months after the procedure.” Similarly, two studies involving autologous stem cell injection for refractory patellar tendinopathy and refractory plantar fasciitis showed statistically significant improvement in most clinical scores including activities of daily living, symptoms, and sport scores; and statistically significant improvement in pain and function scores compared to control groups, respectively.
In summary, Mautner notes that “very little evidence supports use of the traditional treatment model of rest, nonsteroidal anti-inflammatory drugs, and corticosteroid injections, and these treatments are often ineffective at reversing the condition…Injectable stem cell therapy is an attractive alternative because these cells can potentially reconstruct and orchestrate healing of the original tissue architecture.” Evidence for the effectiveness of this modality, the best source to obtain stem cells, and optimal number and timing of injections, among other things is still needed to determine optimal treatment of soft tissue injuries.
For more on the latest research in PRP and regenerative medicine, be sure to attend the The Orthobiologic Institute (TOBI) 6th Annual PRP and Regenerative Medicine Symposium June 13th and 14th in Las Vegas. Save $300 OFF Registration with Promo Code: TOBIBLOG