Regenerative Medicine and the Differences in Injection Therapies
The goal of regenerative medicine is finding equilibrium between repair and breakdown in the body. The body has constant regenerative processes, based in the constant turnover of cells in all tissues of the body. Osteoarthritis, tendinopathies, and ligamentous tears that do not heal are examples of when the breakdown outweighs the repair. Regenerative medicine shifts the body back towards repair finding a balance between repair and breakdown.
Regenerative medicine includes prolotherapy, platelet rich plasma therapy (PRP), and stem cell therapy. Prolotherapy was first referred to as sclerotherapy by Hippocrates during the 5th century when iodine and carbolic acid were used. In the United States, it has been used since the 1930’s and has continued to evolve. PRP has been readily used since the 1990’s and stem cells have been consistently used since 2012 in the United States. All forms of regenerative medicine have the same basic idea: inject a solution into an injured area, stimulate an inflammatory response and promote healing.
Comprehensive prolotherapy utilizes various types of injections to induce inflammation in the joint in order to mimic an injury and bring the body’s own immune cells and healing factors to repair and rebuild injured and degenerated soft tissue or joints. The injection solution varies in its contents, but usually includes some form of dextrose, lidocaine/procaine, and sterile water.
Prolotherapy creates an inflammatory response recruiting fibroblast, growth factors, and other collagen building precursors to the area. In turn this helps with reinforcing connective tissue resulting in ligament/tendon thickening and stability. This therapy is used for chronic myofascial pain, back pain, osteoarthritis, and ligament/tendon injuries. Prolotherapy is also a great treatment for hypermobile tendons and ligaments that have a tendency towards strains and sprains. Ligamentous instability often results in areas feeling tighter or having increased pain in the area. Our muscles tighten in order to compensate for the instability. If healing does not occur as the injury or instability continue our bodies will continue compensating by increasing calcium deposits leading to bone spurs or osteoarthritis.
Platelet-rich plasma therapy involves using your own blood plasma and platelets as an enriched source of growth factors and cytokines. This concentrated source of platelets, growth factors, and cytokines stimulates healing of bone and soft tissue. Our bodies are constantly trying to find equilibrium between breakdown and regeneration of tissues. When we have an injury to a tissue or repeated stress on a joint resulting in osteoarthritis, tendinopathies, or rotator cuff injuries the stronger emphasis is put on breakdown over repair and equilibrium is lost. The goal of using regenerative medicine such as platelet rich plasma injection therapy is to shift the equilibrium back towards regeneration by stimulating an inflammatory response and supplying growth and repair factors to the area helping the body repair and heal itself. This is a therapy that can be utilized for minor tearing of ligaments and tendons, osteoarthritis, plantar fasciitis, ligament instability, and injuries related to overuse.
Currently treatments for osteoarthritis are: bracing, weight loss, NSAIDs, corticosteroids, visco-supplementation and arthroplasty. Unfortunately, these options all have vast limitations and/or severe side effects. A knee replacement on average last 15 years, which is why they are prolonged for as long as possible resulting in people resorting to chronic NSAID and corticosteroid use for pain management. Many papers show corticosteroids lead to: soft tissue damage, cell death and tendon atrophy, reduced bone mineral density, inhibit collagen synthesis, lead to insulin resistance, atrophy of muscles/skin, and depression. Chronic NSAID use has been shown to lead to increased risk of stomach ulcers, acute renal failure and stroke/myocardial infarction. Multiple studies have shown Platelet Rich Plasma therapy to be either superior or not inferior to viscosupplementation of hyaluronic acid, which is the gold standard for OA treatment at this time.
Multipotent stems cells also referred to as adult stem cells can derive cells from the same germ layer, opposed to embryonic stem cells, which is pluripotent and can differentiate into any cell type.
The adult stem cells used in regenerative medicine are mesenchymal stem cells that are found in bone marrow, synovial fluid, and adipose tissue most often. These cells can derive cartilage, bone, muscle, tendon and ligaments. They can also reduce inflammation, secrete cytokines and growth factors to induce cellular proliferation and angiogenesis. Injected into a source of injury or degeneration they become activated, secrete various cytokines, and stimulate a healing response.
Prolotherapy is the basis of all regenerative medicine, using only solutions it works in its simplest form and has stood the test of time for helping the body repair and heal. PRP’s advantage is you are placing your body’s own growth and healing factors in a concentrated location at the site of injury. Instead of these growth factors and collagen precursors traveling to the site of injury after being stimulated they are already there ready to start the healing process. Stem cells have the ability to differentiate into different cells and form connective tissue. A way to think about PRP verses stem cells is that PRP is the fertilizer, it can help things grow. Whereas stem cells are the seed and the fertilizer. Prolotherapy is often thought of for hypermobility of ligaments and tendons and has been shown in research to work in conditions from ligament instability to osteoarthritis. PRP is most useful where there are vascular supplies, muscle tears, tendinopathy, tendonitis, annular tears, and mild osteoarthritis. Stem cells are considered for severe osteoarthritis, degeneration and tears. Many factors go into a doctor’s decision about which therapy is the best for you including age, overall and relative health, and degree of the injury.