If you are unfortunate enough to have arthritis, now is a particularly exciting time, because there are now options that have not been previously available that may actually halt or reverse your arthritis. Below I have summarized all options currently available. They fit into several categories: Holistic, Bandaids, Surgery, and Biologics.
We will start with the holistic category. This group will include all nontraditional forms of treatment. As a whole, there is no data to support their use. This would include glucosamine and chondroitin, cherry juice, prolotherapy, copper and/or magnetic bracelets, and a whole host of other options. This certainly includes the “Miracle Cures” that seem to run rampant in all forms of advertising these days.
While all of these are unlikely to be harmful, they really don’t do much for most patients. Our Academy of Orthopaedic Surgeons actually recommends against the use of chondroitin/glucosamine because all the studies to date have been done by the manufacturers and after 15 years, there is still no data to support its use.
Glucosamine/Chondroitin does make some people feel better because there is a mild anti-inflammatory effect that occurs with use. None of these options can halt or reverse arthritis. Personally, I don’t have strong feelings one way or the other about using these options. If you feel better on them, that’s fine. Just don’t expect much if you decide to use these, and certainly don’t ignore proven treatments.
The second group is the Bandaid group. This includes all traditional forms of treatment and includes bracing, cortisone and gel injections, anti-inflammatory medications, and Physical Therapy. All of these can help with the symptoms of arthritis, but do nothing to alter the progressive deterioration of the joint. Think of cold tablets when you have a cold. They help with some of the symptoms, but don’t make you feel great and certainly don’t shorten the disease. As opposed to holistic options, these have all been proven in a multitude of well designed studies to help control the symptoms of arthritis. Implicit in their use is that one is merely waiting until the symptoms worsen and then either live with significant limitation, or undergo replacement surgery. In general, these options can provide moderate, but not excellent relief of symptoms. Unlike the holistic group, there are documented potential damaging side effects with most of these options. This doesn’t mean they are less safe than holistic options. It means they have undergone the intense study and scrutiny that none of the holistic options have.
Bracing is probably the least helpful of these options, but there is no downside to their use. Most people with arthritic knees will find that a neoprene sleeve makes the knee feel a little better. More rigid unloader type braces can provide some relief during vigorous activity, but are too bulky and uncomfortable to be worn full time.
Cortisone shots can provide reasonable short term relief for an inflamed knee and are frequently the first option many people with arthritis choose. The first shot not infrequently will last several months, but repeat injections end up helping only a few weeks. These shots can be repeated every 34 months as needed. This typically is not a good long term strategy because it ceases to be effective. The cortisone also is detrimental to joint health and actually has been shown to be toxic to chondrocytes, the living cell in joint cartilage.
Gel injections are composed of hyaluronic acid, the same compound that is present in human synovial fluid. The theory behind these injections is that in arthritic knees, the molecular weight of the hyaluronic acid decreases, and by adding a larger molecule, the shock absorbing capability increases. It’s not clear how these shots help because they have been shown in radioactive labeling studies to be no longer in the knee 48 hours after injection. Typically these injections are given in a series, one a week for 3 weeks. Gel One and Synvisc One are single injections. The series can be repeated every 6 months. These injections are intended for and work best in knees that have at least 50% of the joint space remaining on weight bearing films. They work least well when bone on bone findings are present. Numerous studies have shown that the gel injections are no more helpful than cortisone injections, but they do not harm the articular surface like cortisone. Unlike cortisone, 10-20% of the patients may develop an adverse reaction to the gel injections and experience severe pain and swelling within 72 hours of the injection. When this occurs, the patient may not have any more of these injections. These are expensive injections and Blue Cross will no longer reimburse for them. Medicare requires at least 3 months of prior treatment before they will authorize these injections.
Anti-inflammatory medications are the most common treatment for arthritis. They all work by inhibiting the formation of cyclooxygenase 1 and 2 which are precursor molecules in the inflammatory cascade. These medications do not alter the progressive deterioration that is the hallmark of osteoarthritis, but can help with some of the symptoms of swelling, warmth, and pain. As the arthritis progresses, these medications tend to help less and less. I liken them to cold medication, cold medications can make you feel some better, not great, but cannot shorten the duration of the cold. A significant problem with these medications is that heart attack and stroke are associated with their use and can occur early in the treatment course. The risk of this remains relatively low, however. Also, many people do not tolerate these medications because of stomach upset, and ulcer formation is a concern.
Physical therapy can help to improve muscular strength and endurance as well as improve range of motion. This is most helpful when significant muscle atrophy is present. This is almost always is used in conjunction with other treatment options. The degree of joint deterioration usually limits the effectiveness of therapy to significantly improve muscle tone. Non Impact activities such as upright biking, Precor machines, and aquatic exercise can minimize joint irritation while helping to increases muscle tone. Again, this option does nothing to alter the progression of the arthritis.
The third option is surgery. This group includes arthroscopic surgery and joint replacement. Generally speaking, arthroscopy is reserved for joints with meniscal tears and little arthritis. Because arthritis is loss of the joint surface with secondary inflammation and not something extra in the joint causing problems, it cannot be removed arthroscopically. For patients with x ray evidence of bone on bone contact in the joint, joint replacement remains the most definitive and predictable solution.
There has been over 40 years of joint replacement experience and while outcomes continue to improve, complication rates remain low. In a Medicare aged patient, it would be unusual to outlive the lifespan of the prosthesis.
The fourth option is the use of Biologics. Biologics are the only group that has the potential to alter the course of arthritis, possibly delaying or eliminating the need for a joint replacement. These options are considered investigational by third party payers and are not covered by medicare or insurance. The patient pays directly for these treatment options. There are 3 biologic options at this time, ACP, PRP, and Stem Cells. ACP stands for Autogenous Conditioned Plasma. This is obtained by drawing 15 cc of blood from the patient and using a centrifuge to remove the cells, leaving 6 cc of plasma with growth factors. This is then injected into the affected joint. This has been shown to be as effective as the gel shots for patients with intermediate grades of arthritis. Because most cells are removed, it is the least biologically active of the three.
PRP, or Platelet Rich Plasma is typically obtained by drawing 60 cc of the patient’s blood and centrifuging it to remove red and sometimes white blood cells leaving platelets and plasma. In order to qualify as PRP, the concentration of platelets should be at least 3x that of blood.
Platelets have alpha granules which produce multiple growth factors. There are multiple systems for the preparation of PRP with wide variations in platelet and white blood cell concentrations.
Accordingly, although it has been studied for nearly a decade, obtaining a consensus of outcomes has been difficult. There are however, multiple studies demonstrating superiority of PRP over cortisone and gel shots. PRP helps arthritis by turning off nearly 150 genes that have been turned on either by trauma or genetic programming. In an arthritic joint, the cartilage cells called chondrocytes produce toxic substances that cause breakdown of the joint surfaces. The PRP temporarily turns these genes off, possibly slowing the progression of arthritis. No long term studies have been done to prove or disprove this concept. Studies also have shown that PRP with white blood cells doesn’t help arthritis as much as PRP without white blood cells. This is felt to be related to the inflammatory effect of white blood cells on the joint.
Stem Cells are the cells in our body that can potentially turn into any type of cell. These specialized cells have the unique capability of being able to regenerate damaged tissue. While the biology of the stem cell has been elucidated over several\ decades, only recently have we been able to harness their healing capabilities for musculoskeletal problems. This is because not all stem cells are able to regenerate joint tissues. Stem cells obtained from fat, for example, lack the growth factors necessary to reverse arthritis. Fortunately, recent advances have allowed us to painlessly harvest and concentrate stem cells from our bone marrow which has been proven to regenerate joint surfaces and increase meniscal volume. This can be done in a simple painless office procedure with a local anesthetic. Sixty cc’s of bone marrow is typically obtained from the iliac crest (hip bone) or upper tibia bone using the Biomac system. Obtaining bone marrow without this advanced equipment is typically painful. It is then filtrated and centrifuged to concentrate the stem cells for injection into the affected area.
As we age, our stem cells become less active. By adding growth factors to the stem cell injection, your older stem cells will behave more like juvenile stem cells and remain active for longer periods of time. These growth factors are obtained from a specific area in human placentas.
This tissue is called Amnion, because it is obtained from the amniotic side of the placenta. The placentas are obtained from live healthy births from 12 hospitals in the Dallas area. There are no ethical concerns with this, as this tissue is discarded after the birth. All tissue is tested for disease and is sterilly processed. The FDA has approved this process. This tissue comes fresh frozen on dry ice and has to be used within 15 minutes of thawing to preserve the function of the growth factors. Within 7 minutes of exposure to these growth factors, adult non active stem cells change their cellular characteristics and resemble the spindle shaped juvenile more active form. These cells will then remain biologically active for up to 8 months, much longer than non exposed cells. Another huge benefit from the Amnion is that it inhibits scar tissue formation, allowing your body to heal with minimal scarring.
The stem cell functions in two ways. It can transform into the tissue that is damaged as well as coordinate healing. The best way to think of the stem is that of an orchestra conductor. Without the conductor, sound can be produced, but it would be disordered. This is analogous to scar tissue formation. Our body heals injury with scar tissue. With a conductor, the sound is coordinated, not noise. The stem cell coordinates all the cells involved with healing to help regenerate the damaged tissue and minimize scar tissue formation. The true abilities of the stem cell was demonstrated in 1997 when Dolly the sheep was cloned from a single adult stem cell. Platelet rich plasma has been used with some success for years and has been fairly extensively studied. There has been limited success, however, in regenerating normal joint tissues with platelet rich plasma. In this system, the platelet is just one part of the orchestra, not a soloist and healing is much improved.
Because this is an emerging and new technology, there are very few long term human studies to guide us. One study from Malaysia did demonstrate the ability to regenerate near normal joint surface in damaged knees with stem cells. This was the first study ever to demonstrate synthesis of near normal Type II collagen in the joint tissue that regenerated. Type II collagen is the main collagen found in healthy joint surfaces. Without stem cells, Type I collagen forms. This is the main collagen in scar tissue. Another study demonstrated an increase in meniscal (Knee cartilages) volume after meniscectomy. This is important because the meniscus is the main shock absorber in the knee. When it is damaged and removed, the joint surface sees increased stress (up to 275% increase) and subsequently degenerates. Any regeneration of meniscus will minimize the risk of developing arthritis.
In order to understand how stem cells can help prevent arthritis, it is important to understand a little about arthritis. Arthritis isn’t something that gets into the joint, but rather loss of joint surface. Think of 30,000 miles on a tire with the steel belting showing through and you get an accurate picture of what arthritis is about. Arthritis begins when our joint cells, as a result of trauma or genetic programming, start producing compounds which breaks down the joint surface.
This genetic machinery can be turned off with stem cell treatment and halt the progressive damage to the joint surface. cuff healing with stem cell use. At six months from arthroscopic rotator cuff repair, the stem cell treated group had 100% of the cuffs intact on ultrasonic evaluation compared to only 67% of the non-stem cell group. At 10 years, 87% of the stem cell treated cuffs were intact, compared to only 44% in the non treated group.
Another study from France demonstrated superior rates of rotator cuff healing with stem cell use. At six months from arthroscopic rotator cuff repair, the stem cell treated group had 100% of the cuffs intact on ultrasonic evaluation compared to only 67% of the non-stem cell group. At 10 years, 87% of the stem cell treated cuffs were intact, compared to only 44% in the non treated group.