Podcast: Regenerative Cell and PRP Injections to Treat Orthopedic Pain

Podcast Transcript

Hello and welcome to The Bone and Joint Playbook with Dr. John Urse Tips for Pain Free Aging. On today’s episode, Dr. Urse talks with Dr. Brian Ceccarelli, host of Doctors Unmasked on topics of stem cells and PRP injections and how they are changing the face of today’s orthopedics. If you would like to learn more on stem cells and PRP treatment, please check out DrJohnUrse.com

Dr. Ceccarelli: Hey John thanks for allowing us to come in and talk about this topic today of ortho biologics and regenerative medicine looking forward to hearing all of the information you can give us. I know you’re an expert in the area so I’m looking forward to talking to you about it.

Dr. John Urse: Yeah well great, pull up a chair lets have a seat.

Dr. Ceccarelli: So John you mentioned the stem cells being a treatment option for arthritis. First of all can you tell me what arthritis is? I think there are misconceptions about what exactly arthritis is. I think that would be a good starting point.

Dr. Urse: Well arthritis comes in various forms there are some that are wear and tear forms that are degenerative or osteoarthritis, some people get arthritis from rheumatological problems, gout or other what are called inflammatory conditions. But either way the cushioning effect of the cartilage which is the gristle at the end of the chicken bone, we have all seen that white cartilage. That is what causes the spacing and cushioning to let our joints move and move freely without pain. As we lose that cushioning or softening, you may have heard the word chondromalacia which is a word for soften cartilage and that softening as it progresses causes the bones to rub on each other. So in a picture of a knee here with a space between the bones the cartilage is good on a normal knee as a weight bearing x-ray shows bone on bone occurs when the cartilage wears down and the bones rub together much like a missing break shoe pad on a car, it hurts.

Dr. Ceccarelli: So the bone rubbing on the bone is what gives the patient the pain they have?

Dr. Urse: Yeah because bones have nerve endings that’s why if you’ve ever broken a bone it hurts. Those edges of the bone are now rubbing against the other bone in the knee.

Dr. Ceccarelli: So what I’m hearing then John is if your saying these stem cells actually have the ability to regenerate cartilage, if you inject a stem cell in an arthritic knee you would actually see that space again?

Dr. Urse: Well, not right away, and that is a good question Brian. There have been some studies and some of them were pretty well thought out. They looked at a MRI of a patients knee before they had any stem cell injections and then they repeated those studies at three six and twelve months looking for cartilage growth after stem cells. You don’t see much for that first six months but at twelve months almost everybody had thicker cartilage or cartilage growth and they confirmed it with either an MRI or what they call a second look scope where they actually look in the knee with a light. So we’re getting two things happening with stem cells. The first is the most important thing, those are the pain and anti-inflammatory factors that turn off the pain generators in the joint. Those occur pretty quickly and that’s what makes people feel better sooner, but if your question is when is my x-ray going to go back to this, the answer is maybe never but if it helps with cartilage growth over time it should help with the cushioning of the knee and may help with the appearance of the x-ray over time, but that’s not a very quick fix in the regrowth department.

Dr. Ceccarelli: But some gristle or cartilage is better than bone on bone obviously.

Dr. Urse: It is but we have people who are pretty happy early and we know the cartilage hasn’t regrown according to the studies, we think it’s the what are called anti-inflammatory effects of the growth factors that are in the stem cells and there are quite a bit more in those than the other thing we talked about with the platelets.

Dr. Ceccarelli: So when you talk about stem cells John, and you mentioned there are different types of stem cells, where exactly would you get the stem cells from as an orthopedist that was going to do an injection to treat someone with that problem?

Dr. Urse: Well I recommend a bone marrow aspiration which means we draw the stem cells from the back of the pelvis, there is an area there that is easily assessable and we draw the stem cells out of the bone marrow and we them in a spinning device which is called a centrifuge so it concentrates them into a high concentration, but also removes part of the blood that we don’t want to put in the knee that will irritate the knee. So we remove the red and white blood cells but we want some of the platelets and stem cells that are going to be put into the knee and that’s what gets injected with a stem cell injection into the joint.

Dr. Ceccarelli: Can you tell me how we do this exactly.

Dr. Urse: Sure Brian, first of all we are going to call you in a medication that is going to relax you, you are going to take that about an hour before you come and you are going to have somebody drive you in. When you come back into the office we are going to have you lay down on a table like this and I am going to come in with my ultrasound machine and will numb up an area on the back of the pelvis with some Novocain just like you would get at the dentist. Now what that will do is numb up that area where I am going to draw the stem cells. You will then feel some pressure when we draw the blood, that area is then covered with a band-aide and you will lay there for about 15 minutes and I go “Brian are you comfortable?” and if you are the spinner devices takes 15 minutes to concentrate your blood. Then I say, “Brian why don’t you sit up” and then I take the ultrasound machine, take the stem cells and put them in the knee, we numb up that little area of the knee for you and put the stem cells in and then you’re ready to go. It takes about an hour in the office and whoever is here to drive you home has a couple things for you, a few mild pain medications if you need them and we tell you to ice it, go home and turn on a ballgame and thats it.

Dr. Ceccarelli: Stem cells sound like they are the beginning of cells that can differentiate into different cells as necessary for repair. Is that pretty accurate?

Dr. Urse: Thats a good statement. They really are kind of like soldiers. They can be centries, administrators, they can be this or that. So again where they have to go they’re waiting to see what they need to do. They can be muscle or fat or they can be bone or they can be cartilage. It depends what the body asks them to do, they not only go to the area where we placed them, they recruit other cells to come and help them. So they are kind of like construction foremen who don’t do all the lifting themselves, they’re recruiting other cells to your knee, hip, shoulder or wherever we put them. If we were to tag the cells with special tracers that we take out of your back and put into your knee, the ones later that help grow the cartilage may not even be those same cells, they’re bringing other cells to that area which is a cool thing they can do.

Dr. Ceccarelli: So stem cells John are different from when you talk about PRP or platelet rich plasma, correct? Thats two different topics really?

Dr. Urse: That is important for patients to know that because if they say, “Oh I just went and had a stem cell injection from my arm.” Well there are no stem cells in your blood in your arm, ok? Platelets are apart of blood and they help with clotting and they’re useful for mild conditions of arthritis or the things we talked about with tennis elbow or kneecap arthritis problems, or some of the things where you have tendonitis of your ankle or different areas of your hip muscles called the glute tendons. We have put platelet injections in those. The stem cells are only in certain places. They’re in fat there in bone marrow and there are some fetal or what we call embryonic sources that come from other places like a placenta from a c-section delivery. But, that is going to be from another person and those cells are really activated or alive but they are fetal cells. So i think the patients and the consumer need to know where they’re coming from and what they are and be sure they’re getting what they think they’re getting.

Dr. Ceccarelli: So lets focus on PRP for a second then. So PRP or platelet rich plasma is also used to treat conditions that are orthopedically related, correct? I remember a football player tearing an achilles or having an achilles strain and reading where he went into his doctor and got a PRP injection. Was that to accelerate healing?

Dr. Urse: It was, it was done to do two things, cut down inflammation and pain but also improve healing and recruit what are called growth factors. Platelets have a tremendous amount of growth factors, over 1,200 different types. Some are in the vessels, some are in the different cells, but those various growth factors help with healing, speedy recovery. We even see open heart surgery patients who get their breast bone closed after surgery have a PRP injection placed along the incision line of the bone to help it heal faster and reduce that pain. So when they put it in an achilles tendon or a Tommy John ligament of the elbow or a muscle tear of the hip or knee, those are meant to decrease pain and improve function. Now it is important to make sure its nota complete tear where its detached because nothing is going to repair something that is completely detached. So we are talking about where inflammation or partial tearing or fraying is occurring or where a ligament has been partially stretched. Those ligaments and tendons are some of the other applications of the platelets in ortho biologics that we use that aren’t related to just arthritis.

Dr. Ceccarelli: You had mentioned that you do the stem cells from the bone marrow and you also kinda eluded that you get the PRP from drawing blood, is that correct?

Dr. Urse: That is correct.

Dr. Ceccarelli: So would I do that? So if you saw me today and said “Brian you have an arthritic knee” and you saw my x-ray would I then go right back and you would do a bone marrow aspiration that day and inject it? Or how does that work? How does the typical visit work when you give me that option.

Dr. Urse: Well if you’re seeing me for the first time and we are doing an initial evaluation, I examine your knee, look at your films if you have them and they have already been taken you can bring those with you. I prefer the actual disc and MRI if you have those. After I talk to you then I say well Brian this is what I think you can do and I review that your knee may have bone on bone and that a knee replacement is an option but there are safer options or less invasive or options that would delay having a joint replacement. So I would recommend a stem cell injection with platelets because there are additional benefits of those anti-inflammatory proteins in the blood that we can get combined with the stem cells.

Dr. Ceccarelli: So John now comes the segment where I am the patient. I get to take off my mask as a physician and become the patient in your office. So I would like for you to try and keep your answers as simple as you would, try to keep them as if I were a patient asking you these questions so they get a better understanding of what information you want to get across. So you just recommended to me that I get a stem cell injection into my knee. Can you show me on my knee where I would get that injection?

Dr. Urse: Sure Brian, I would have you lay back we would do it right on the outside part of the knee using an ultrasound to guide it into the joint and that is simply an injection of the stem cells that go into the knee joint which is a capsule which holds all of it in that area.

Dr. Ceccarelli: So am I awake for this part of the injection?

Dr. Urse: You are. You’ve got a little area of the skin is numbed up with Novocaine and that part numbs it up where the needle stick goes and after that its like an injection you may have gotten with cortisone or a gel shot in the past.

Dr. Ceccarelli: So will I be able to walk out on my own?

Dr. Urse: You will you will have a little more fluid in the knee, there will be about 4-5 cc’s of fluid so that fullness can make the knee feel a little tight. You may limp a little but you have the option of bringing a walking stick or crutch, but most people walk out.

Dr. Ceccarelli: Will I be able to drive home if I came myself?

Dr. Urse: I usually don’t recommend that because if we do a stem cell I give you an Ativan relaxing medication ahead of time so we prefer someone drives you here and takes you home. The whole procedure would be done inside about an hour and the medication really hasn’t worn off by that point.

Dr. Ceccarelli: Ok, so can I go back to work that day?

Dr. Urse: I don’t recommend that either, you just had an Ativan Brian. So I think the best thing is to go home take it easy we tell people to not over do it, even the next day not to be up more than about 30 minutes at a time that first day after doing stem cells.

Dr. Ceccarelli: Ok, how about a PRP injection? Would you have the same restrictions on me if I had a PRP injection?

Dr. Urse: Not at all. Those are simple injections of your platelets those go into the knee much like a cortisone shot, you can do regular activities, you can drive, we don’t give you a premedication for that. So normal activities that day and the next day.

Dr. Ceccarelli: Ok, just so I understand. PRP I can come in get a shot and drive myself and go back to work. Stem cell injection you’re going to give me some sort of light sedative by mouth, and you recommend I come in with somebody to take me home that day.

Dr. Urse: That’s correct.

Dr. Ceccarelli: Ok, so John you had mentioned cortisone a couple times in this brief conversation. So why would I get a stem cell or PRP injection as opposed to a cortisone injection?

Dr. Urse: Well, the cortisone is a fast-acting injection of an anti-inflammatory medication, a steroid. So, it’s going to work quickly it’s going to get you down the aisle for your daughter’s wedding next week, but it may wear off though in six to twelve weeks, so it’s not very long lasting, but its fast-acting. The gel injections or what are called the viscus injections or visco supplements, which are not covered by all the insurances but most of them right now, is about a six-month lubricant for the knee, it’s not a medicine its more of a gel or cushioning effect. The platelets will last twice as long as the gel shots, they should last a year to a year and a half, those are for mild forms of arthritis. The stem cells are for more severe or advanced arthritis cause the stem cells have a lot more anti-inflammatory potential but also more importantly cartilage regrowth potential, and those can last for many years and those are done for a longer lasting effect on a more advanced arthritic condition.

Dr. Ceccarelli: So, we’ve talked primarily about the knee, I’m here, you said I need it in my knee, but can I get PRP or stem cells in any joint that I have?

Dr. Urse: You can, they don’t fit too well in small joints of the hand, one of my partners is doing a study on the base of the thumb joint with platelets you can only get about a drop or a cc or so in that small joint, but the stem cells are being done predominately for me in the hip, shoulder and knee, we are doing some ankles there are people who do spine injections and some of the selective injections along the spine you may have heard Jack Nicklaus went to Munich to get a stem cell injection into his back. So, there are places that do more selective cites like the spine those are just emerging in some of the areas of the country now.

Dr. Ceccarelli: You know before I came into see you John, again playing the role of a patient, I read that stem cells come from embryos. Is that true is that the kind that you use?

Dr. Urse: Well, it’s not the kind I use but there are three main sources for stem cells. Our own bone marrow, which is where I take it from, our own fat and fat or whats called adipose tissue isn’t currently approved by the FDA for joint injections because it’s not where fat normally is. So, the FDA wants you to put things that should be somewhere in a place that is similar.

Dr. Ceccarelli: So, you’re not doing embryo on me?

Dr. Urse: No, but the other source is a fetal source called an embryo there are stem cells in the placenta and the amnionic tissue the problem with that is that it’s someone else’s tissue, those cells are not live. They are taken when someone has a c-section those cells are put in a syringe there packaged. Those injections are fetal cells, but if you look under a microscope, they’re not living cells and they’re certainly not very active but that is the source that they’re from. So, there are some stem cells in fetal tissue, I just don’t choose to use those.

Dr. Ceccarelli: To my reading before I came in because I was anticipating that I might get this recommendation to get a shot. In my reading there is a little bit more FDA scrutiny over those embryonic stem cells then something you’re going to take from my own hip, correct?

Dr. Urse: The FDA says as long as we are taking the patient’s own blood and putting it back in the patient without altering that, because we can’t grow it in a lab dish, we can’t keep it overnight and duplicate it or multiply those cells, as long as were not changing what it is, we are simply taking away things that aren’t good for your knee, some of your white blood cells and red cells are harmful to your knees, we don’t want those in the stem cell injection for the knee, so we separate those out with a special spinner device, we will talk about called a centrifuge. So, we want to make sure we get the right things in the place we need to. So, the FDA is fine if we do that with a patient’s own blood.

Dr. Ceccarelli: Ok, now I had told you also that I had lateral epicondylitis or tennis elbow. You had mentioned that we might be able to do a shot for that. What kind of shot would you be able to do for someone with tennis elbow? Is it the same process?

Dr. Urse: It’s a similar process, but it’s easier because it only needs a PRP or platelet injection. There are two types of platelet injections one with white blood cells that you want an inflammatory response to stir up healing, that’s the kind we use on an elbow. In fact, the studies that are out about treatment of tennis elbow show, a single platelet injection using ultrasound to get it in the right place, works better than a cortisone shot or physical therapy for that problem for up to two years. That doesn’t mean that if there is a torn little tendon there that it wouldn’t need a surgery someday which might fix it definitively, but if your busy or working hammering a house together, you might want to have a up to one-to-two-year improvement of your symptoms with a simple PRP injection.

Dr. Ceccarelli: And if I recall, you were saying that’s where I would come in and you would get blood just like if I were giving blood at a center, and you would take my blood spin it down in a centrifuge come back with a small amount of PRP and just inject it again under local right here and I would leave.

Dr. Urse: That’s correct. That’s just a simple more powerful injection cause platelets have about 1,200 anti-inflammatory proteins that help that pain and inflammation in the elbow, and that’s the stuff we want in the area of injury or pain or disease.

Dr. Ceccarelli: So, I just have a couple more questions but some of these I think are really important because I just got a new insurance plan, and I don’t know whether or not they would cover this type of injection? Is this a commonly covered type of injection? Cortisone is typically covered by insurance, right?

Dr. Urse: Cortisone is almost always covered.

Dr. Ceccarelli: Ok, how about the PRP and stem cells?

Dr. Urse: It varies. Most of them do not cover it completely, but there are some insurance carriers who are doing some of them as a way to delay a joint replacement surgery. Some of our older patients who have heart conditions we like to do them in a hospital setting where we monitor the heart. The anesthesia people give a sedative by vein and then that bill is sent to the insurance from the hospital and then the hospital fights it out with the insurance company over who pays what and how much. Some of the carries are coming around to paying quite a bit of that, I don’t get a lot of complaints from my patients, so I think that is part of what I call the wild west right now of biologics where these cell injections are being given, but there aren’t codes for these yet, so the insurances don’t know, and the hospitals aren’t sure. That’s why I probably do 3/4ths of my injections in the office here where we know we don’t involve the insurance or hospital and we know there is a set fee and the patient knows what it is going in and if they choose to do it, we think we have very reasonable pricing for it which we give them if they’re interested.

Dr. Ceccarelli: So, you mentioned a total knee is an option. I have bad arthritis in my knee, and you said this may delay the need for me to have a total joint replacement, is that correct?

Dr. Urse: Well, that’s what I tell my patients. So, I think my job is to give you these options of what you can do for your problem. The injections I go through those four things we just talked about, the cortisone, the gel the platelets for mild problems and the stem cells for more severe problems. I tell them you always have the option of replacing a joint, that’s the hip knee or shoulder, but these stem cells that can grow cartilage and cut down inflammation can delay that for many years. Our outcome studies in North America are in the four or five year category we think it may be longer than that, we just don’t have those numbers here because the technology is fairly recent in the North American market.

Dr. Ceccarelli: One last question then, would you ever consider doing this on a family member?

Dr. Urse: Well, I have to say I have already done it on a family member, my wife’s hip was, well still is pretty bad. She was diagnosed with some hip issues years ago that were bad enough to need a hip replacement. I was smart enough to not be the one who was going to do it so I took her to a doctor who said yep that’s what you need, and she said no thanks I don’t want it right now. I put stem cells in my wife’s hip 3 years ago, actually, over 3 years ago and she still hasn’t had her hip replaced. She takes one or two anti-inflammatories a month if she over does it, but she is pretty happy. She has her own hip and is delaying what she knows is going to be a hip replacement someday, but her thinking is that the longer she delays it, whenever she decides to do it maybe it’s going to last longer and not have to be redone later in her life. For her it has worked out great, I’m living with it, so I know when things work or don’t work, and I think she’s a pretty good testimonial for what I’ve seen.

Dr. Ceccarelli: Well, Dr. Urse thank you. I think that the questions that I asked were relevant and I think you answered them in a manner I can understand them, I appreciate you taking the time to explain all of this to me, and I look forward to reaching out and getting that shot.

Dr. Urse: Alright, well thanks Brian.

Thank you for joining us today on this episode of The Bone and Joint Playbook, with Dr. John Urse, Tips for Pain Free Aging. Please join us again for another episode. This has been a production of Doctors Unmasked, produced by Terry O’Brein.