Overview of Regenerative Therapy in Pain
Regenerative medicine is a field which has been around for many years. It uses the body’s biological capabilities to replace or rejuvenate organs, cells or tissues which are diseased or damaged. The US Food and Drug Administration has approved a few treatments in this area, especially for helping wounds heal and fixing problems in our bones and muscles. There are four main types of techniques that are commonly used in regenerative medicine: viscosupplementation, platelet-rich plasma, stem cells, and prolotherapy.
Viscosupplementation is a process where a substance called hyaluronic acid is injected into the area around a joint affected by osteoarthritis. This is done to restore the thickness and elasticity of a fluid called synovial fluid in this region. This fluid is crucial for absorbing shocks, reducing friction, and providing a cushioning effect to the joint.
Prolotherapy involves the injection of a solution into a compromised structure to help restore it and encourage ‘sclerosis’, or hardening, at that site. A key difference between this and the other regenerative medicine methods is that the injection contains no biological components. In prolotherapy, a substance called hypertonic dextrose is often used. Its job is to stimulate the body’s inflammation process, which is a key part of the healing response.
Platelet-rich plasma is another technique where a component of your blood that is rich in biological proteins called platelets is used. These platelets have the power to encourage healing and reduce inflammation and pain in the body.
Mesenchymal stem cells form the fourth technique; these are specific types of cells that meet certain criteria. These include being able to stick to plastic when cultured in a lab, expressing certain markers (which are like flags on the surface of these cells) called CD73, CD 90, and CD 105 but not others. Additionally, these cells have the power to turn into osteoblasts (cells that form bone), chondroblasts (cells that produce cartilage), and adipocytes (cells that store fat) in lab conditions.
Why do People Need Regenerative Therapy in Pain
Viscosupplementation is a treatment method approved by the FDA for knee osteoarthritis, a condition characterized by the deterioration of the cartilage in the knee joint. This method is most effective for patients who have not responded to other treatments such as physical therapy, pain relievers like non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, or draining fluid from the knee. People of all ages with any stage of osteoarthritis can benefit from this treatment, as well as those who are not ready for invasive surgical procedures.
Furthermore, viscosupplementation is also recommended for patients suffering from levels 1 to 3 of Kellgren-Lawrence osteoarthritis stages. Those in level 4 who wish to delay knee replacement surgery can also choose this treatment. It may be used for patients dealing with multiple health conditions who are taking various medications, and those who cannot use NSAIDs due to problems with their digestive system, kidneys, or unstable blood pressure.
Prolotherapy is another treatment option for osteoarthritis, degenerative conditions, muscle pain, spine and pelvic pain, tendinopathies (a group of conditions that involve a tendon), and plantar fasciitis (heel pain). It involves the injection of a substance, typically dextrose, to stimulate the body’s healing process in the affected joint. The goal is to increase the strength of the joint’s supporting structures. This treatment method is founded on research showing that certain concentrations of dextrose promote growth and repair in cells crucial to joints, tendons, ligaments, and cartilage.
Platelet-rich plasma (PRP) therapy employs components of your blood to treat conditions like osteoarthritis, ligament injuries, muscle injuries, tendinopathy, and spine disorders. There are two main types of PRP: leukocyte-rich PRP (LR-PRP), which is packed with white blood cells and associated with anti-inflammatory effects, and leukocyte-poor PRP (LP-PRP). Research suggests that LR-PRP may be better suited for tendinopathy, while LP-PRP could be more effective for osteoarthritis.
PRP therapy has garnered a lot of attention due to its potential to regenerate tissue, alleviate pain, fight infections, and reduce inflammation. During the treatment, platelets, which are small cell fragments in your blood, are injected into the injured area. These platelets release growth factors and other important proteins that help promote tissue repair and healing.
Finally, mesenchymal stem cells (MSCs), a type of cell that can transform into a variety of tissue types, are another treatment option with applications that depend on the source of the cells. They can be obtained from bone marrow, fat tissue, the umbilical cord, muscle, peripheral blood, and amniotic fluid. Bone marrow-derived MSCs might be used for specific conditions like hip osteonecrosis (the death of bone tissue due to a lack of blood) and osteoarthritis of the shoulder, while MSCs derived from fat could be used for lateral epicondylitis (tennis elbow) and Achilles tendinopathy. MSCs from amniotic fluid may prove helpful for plantar fasciitis (heel pain).
When a Person Should Avoid Regenerative Therapy in Pain
Depending on the type of regenerative medicine treatment used, there might be different reasons why someone can’t receive it. Some common reasons not to use these treatments include having an active infection, either throughout the body or where the injection would be given, and having a disorder that affects the body’s ability to stop bleeding.
Each specific treatment also has its own set of reasons why it might not be suitable. For example, someone shouldn’t have a treatment called viscosupplementation if they have poor vein circulation, an allergy to a substance called Hylan, or an egg allergy, since some of these products come from rooster combs. Stem cell therapy should also be avoided for those with bone marrow-based cancers or other conditions that result in a weakened immune system.
Platelet-Rich Plasma (PRP) treatments specifically, shouldn’t be given to those with very low platelet counts, problems with platelet function, or instability in their overall health condition. It’s also not recommended if someone has bone or blood cancer, anemia, used non-steroidal anti-inflammatory drugs (NSAIDs) within 48 hours of the procedure, had a corticosteroid injection of the knee within a month, or used systemic steroids within two weeks. PRP therapy should be avoided in case of active rheumatological disorders, corn allergy, or usage of drugs that lower the immune response.
How is Regenerative Therapy in Pain performed
Viscosupplementation is a treatment option involving hyaluronic acid (HA) injections, which can usually be done quickly in a doctor’s office under local anesthesia (meaning you’ll be awake, but the area will be numb). Normally, about 2 to 4 milliliters of HA is injected directly into the joint capsule to treat the discomfort. After the injection, patients are recommended not to put too much weight on the joint for the first 48 hours. Following this procedure, it’s helpful to have physical therapy to benefit joint motion and function.
Prolotherapy is another treatment option that frequently uses a medical fluid called dextrose. Dextrose levels higher than 10% tend to cause inflammation, while levels lower than 10% are not inflammatory. However, it should be noted that while the FDA has approved dextrose for injections, it has not specifically approved it for prolotherapy. The use of dextrose in this context is considered off-label, meaning it’s used in a manner not specified in the FDA’s approved packaging label.
Plasma-rich platelet (PRP) therapy involves using the patient’s own blood. The blood is spun twice in a machine (a process called centrifugation). The first spinning step separates the blood into different parts. The second spinning step is done at a faster speed to further separate growth factors—substances that stimulate cell growth. The end result, the PRP product, is typically 1.5 to 8 times more concentrated than the original blood. This is typically activated by substances like calcium chloride, bovine thrombin, or autologous thrombin.
There is also a therapy using Mesenchymal stem cells (MSCs)—cells that have the potential to develop into many different types of cells. For this, around 60 milliliters of bone marrow is collected and spun to produce about 6 milliliters of concentrated bone marrow. MSCs can be collected from various tissues, including bone marrow, fat cells, and amniotic tissue (the sac that holds a developing baby inside a woman’s womb). Bone marrow is commonly taken from the iliac crest (the top part of your hip bone), and this is usually done under anesthesia due to potential discomfort.
Possible Complications of Regenerative Therapy in Pain
Regenerative therapy, which involves using the body’s own healing abilities to fix damaged tissues, is generally safe. The most common side effects are swelling, pain, or stiffness at the injection site. Although very rare, there could be specific complications like joint bleeding, joint infection, seizures, lung clots, and severe allergic reactions. But stem cell therapy, a type of regenerative therapy, is usually well-tolerated. The main reported side effects include low-grade fevers.
Platelet-rich plasma (PRP) injections, another form of this therapy, are safe as well. Since PRP uses the patient’s own blood, there’s no chance of an allergic reaction or immunity problem. Though, infection and pain can happen at the injected area. In some cases, bovine thrombin, from cows, has been used to activate PRP, but this carries a risk of blood clotting issue. If this leads to the levels of the human ‘factor V’ (which helps blood clot) falling below 30%, it can increase a patient’s risk of excessive bleeding. Therefore, these days, human or synthetic thrombin is generally used instead.
Prolotherapy, another type of regenerative therapy, has very rare side effects like disturbed sleep, root nerve pain, irregular periods, and headaches from lumbar punctures. Extremely rare effects reported include meningitis (brain and spinal cord inflammation), adhesive arachnoiditis (inflamed brain and spinal cord linings sticking together) and encephalomyelitis (brain inflammation).
What Else Should I Know About Regenerative Therapy in Pain?
Research and analyses show that injections of hyaluronic acid (HA), a substance present in the body that keeps joints lubricated, are safe and effective in reducing knee pain and improving function in patients. Research has shown its ability to improve pain and the ability to move for up to 26 weeks.
Prolotherapy is an option that treats chronic pain economically and with minimal intervention. This therapy involves injecting an irritant solution into the body, like sugar mix, to stimulate healing. Studies have shown it to be effective for chronic pain linked to musculoskeletal conditions, conditions affecting the muscles and bones, such as tendinopathies (damaged tendons) and osteoarthritis (joint inflammation due to wear and tear). More studies are needed to determine a standard procedure for providing these injections.
Another treatment used for conditions like osteoarthritis, ligament injury, meniscus injury (damage to the knee’s shock absorber), muscle injury, tendinopathies, and spine disorders is PRP (Platelet-Rich Plasma). Using PRP involves taking a sample of the patient’s blood, spinning it to concentrate the platelets, and injecting them back into the patient’s body. This treatment has shown results in chronic tendinopathy management. However, differences in preparation methods and after-treatment care can lead to varied outcomes. PRP is found to have improved pain and function in patients with knee Osteoarthritis, with relief upto 1 year. PRP appears to be more beneficial in early stages of knee Osteoarthritis than HA injections. But, PRP hasn’t shown any significant benefits in treating hip osteoarthritis.
PRP is now being used to treat ligament injuries as it might improve the outcomes of anterior cruciate ligament reconstruction, i.e., the reconstruction of the ligament stabilizing the knee. Documentation is needed to prove its safety and benefits.
Researchers found that PRP could be used as a potential treatment for low back pain, often linked to disc degeneration and facet joint osteoarthritis (wear and tear in the joints that connect the spine’s bones). Lab studies showed that PRP encourages cell growth and counteracts inflammation of nucleus pulposus cells, the spine’s innermost cells, but high-quality clinical studies are few. Some small-scale studies did show PRP to be safe and beneficial in treating back pain related to the discs and facet joints, but more sturdy proof is needed. There is also evidence suggesting that using bone marrow concentrate can be effective in treating knee musculoskeletal disorders.
