- What is a stem cell?
Stem cells are our own body’s ancestor cells which can – in
theory – become building cells for any organ of the body. Stem cells
begin to develop as soon as the blastula, that little ball of becoming-baby
cells in the womb starts to elongate and differentiate into organs.
- What is the purpose of stem cells?
When the body is injured, it puts out certain “I am hurt” signals
called inflammatory cytokines which attract potentially healing cells
through the blood stream to the area of injury. In theory, every area
of the body has access to these cells, since every area of the body except
the cornea has its own blood supply. Every organ of the body so far investigated
has its own version of stem cells – even the teeth, although so
far the process has been limited to the spontaneous replacement of “baby”
teeth with “adult” teeth. We have not yet seen re-growth of
an adult tooth.
So far stem cell therapy in one form or another has been used medically
for a multitude of conditions, with variable success.
Injection into painful arthritic joints has the most experience behind
it – both animal experiments and human treatment.
Stem cells have been injected into painful knee joints, even sometimes
with injured or missing cartilage, with excellent results in both pain
reduction and restoration of the cartilage.
- Where and how are stem cells produced?
Every organ tested to date has shown to have a certain number of organ-specific
cells which can be coaxed or forced into becoming mature cells of that
organ – kidney for kidney, muscle for muscle, even nerve for nerve/brain.
Some places in the body have more immature cells which can become (differentiate)
into multiple types of cells. Cells in the bone marrow can be persuaded
to become blood cells of many types. They have also been shown to produce
muscle, or cartilage, or bone, or even nerve cells. Cells in the fatty
tissues of the body produce cartilage, bone and nerve cells as well.
- How does the healing process occur?
The healing process often starts by injury to a blood vessel. Every place
in the body – except the cornea –is well supplied with capillaries.
Some of the capillaries are so small that red blood cells have to squeeze
themselves into interesting shapes in order to get through the tiny tunnel.
Platelets are attracted to the site of injury. They are activated by compounds
secreted by injured tissues, producing factors which induce clotting at
the area of wounding. Thus when we are wounded, most of the time we do
not bleed to death, but rather begin to heal the wound immediately.
Why do we need to treat anything with stem cells? Why doesn’t the
body just do its thing and heal?
Why is a big question. Often the body does “do its thing”,
for example when the skin is cut, the body closes the wound – albeit
with a scar. When a bone is fractured, the body speeds up building of
bone at the site of the fracture, and healing occurs.
When the normal healing process does not occur, we can be of assistance
by encouraging healing through a medical procedure called stem cell therapy.
- What is the procedure for “stem cell therapy”?
Stem cells are harvested from various places in the body – blood,
adipose (fat) tissue and/or bone marrow. The tissues are then washed to
eliminate anything used in the harvesting procedure that is not made by
the body. The washed stem cells may then be inhaled into the lungs using
a nebulizer (in the case of severe COPD) or re-injected into the body
in various locations such as painful joints, injured ligaments or tendons.
One excellent method, currently under negative scrutiny by the FDA, involves
separating the stem cell containing fraction of adipose tissue from the
fat cells themselves, and infusing only the stem cell fraction (called
the Stromal-Vascular Fraction or SVF) with its pericytes – cells
which adhere to blood vessels all over the body. These pericytes migrate
to areas of injury when the call is sent out by the platelets. Unfortunately
the FDA seems to be of a mind to consider the SVF cells to be a drug rather
than a body part, and therefore subject to their lengthy and expensive
“Investigational New Drug” application process. For more information
about this issue,
click here and
- Does stem cell therapy hurt?
Drawing blood requires the use of a needle – just like any other
blood draw you would do at a regular lab.
Harvesting adipose tissue is a little more complex – but not a whole
lot. The local anesthetic stings, but then blocks pain nerves, so generally
only pressure in the fat layer of the abdomen is felt. You wear a compression
bandage for a couple of days, so as to minimize any potential bleeding.
Harvesting bone marrow also requires the use of a local anesthetic to deaden
the skin and the periosteum (covering) of the bone from which marrow is
withdrawn. You will feel a pulling sensation as bone marrow is withdrawn
into the harvesting syringe.
- If I am having therapy on a painful arthritic joint, how soon can I use
the treated extremity?
After the procedure we encourage gradually increasing use of the extremity.
We recommend physical therapy to help with gradually increasing use of
the involved joint – including strengthening exercises to help build
up both joint motility and flexibility.
If a weight bearing joint like knee or hip is injected, we discourage weight
bearing for the first two days to allow for maximum healing. After the
first two days, gradual weight bearing is permitted. By the end of two
weeks there is full weight bearing, and you should be experiencing significant
If the joint is the shoulder or wrist, we discourage use of the treated
arm for two days, followed by gradually increasing use with both range-of-motion
and strengthening exercises.
- How soon might I see an effect, if I decide to do cell based therapy?
Healing begins almost immediately, as the body’s own healing cells
begin to release their growth factors. There may be some soreness in an
injected joint during the first 2-3 days as those growth factors begin
to call out the body’s healing mechanisms. Or there may be relief
of pain. Everyone has a slightly different response. In any case, most
people will begin to feel relief within two to three weeks. The relief
may not be 100%, but almost always pain is substantially less.
One study from Australia reported that symptomatic improvement was achieved
within one week of the first injection. That study used photoactivated
PRP as its treatment modality..
 (See below for a more complete description of photoactivation.)
Some case series published have shown 50% or more pain relief after the
first injection of cell therapy. One study from Iran reported on patients
five years later after a single treatment. These patients, even after
8 years, were still in less pain and more functional than before the treatment.
Their pain relief was not complete, but still significant after five years.
- How many treatments will I need?
Some people heal completely after one treatment. Others – particularly
those with badly damaged joints like arthritic deformed knees –
may require up to 3 or 4 treatments. It depends on how healthy the damaged
tissues are at the outset, and how willing you are to modify diet and
lifestyle to allow for minimum inflammation and maximum healing.
Three treatments for a damaged arthritic knee joint is about the average.
- Are the additional treatments included in the cost of the first treatment?
Additional treatments cost somewhat less than the first one. The same follow-up
visits are included with cost of treatment. The same healthy food choices
are recommended and the same stem-cell building supplements.
Lifestyle change is crucial, for maximal healing and lasting benefit.
- Does stem cell therapy work only where it is injected?
You have probably read about surgical implantation of stem cells into the
brain or spinal cord, into the pancreas or the lungs, in an effort to
heal disease in these organs. An interesting paper written in 2014 by
researchers at Tulane School of Medicine demonstrated convincingly that
stem cells liberate their growth factors wherever they are injected, and
can have an effect far distant from where they are initially injected.
In this mouse study, stem cells were injected into the abdominal cavity
to treat a mouse model of multiple sclerosis, and were found to be effective
in reducing tissue damage and inflammation. Stem cells are well known to home in to areas of acute injury, but the
liberation of their growth factors affects the entire body. It seems like
a pretty efficient way to help the body invoke what it normally produces
- How do you decide which form of cell based therapy to use?
There are three forms of therapy which can be used. All have been proven
effective under some circumstances. None has been shown to be 100% effective
in all circumstances.
Platelet rich plasma, adipose-derived mesenchymal stem cell (MSC) and bone
marrow are the three modalities most likely to yield lasting results.
How many of these therapies we use at one time depends upon the severity
of the illness or injury, your physical condition, the extent of damage
to the joint, and how much therapy you choose to do. The three forms of
cell-based therapy are additive, and do not appear to interfere with each
other. In the ideal world, we would use all three forms to maximize healing
- What are platelets?
Platelets are tiny pieces of a cell in the bone marrow called a “megakaryocyte”.
They are little bags of growth factors which encourage the formation of
a clot. Their number can be measured, and the amount of clotting factors
which appear in the blood can be measured. Platelets also produce many
chemical messengers – small proteins, also known as peptides –
which call stem cells to the area of injury to initiate the healing process.
- How are platelets obtained?
Platelet Rich Plasma (PRP) is isolated from your own blood by a process
called gradient density centrifugation. During this process about 60 cc
(about 4 tablespoons) of blood is drawn from your vein and then centrifuged
at low speed to separate the red cells from the clear serum. The platelets
are found concentrated in a layer between the serum and the denser red
cells. This layer, called PRP (platelet rich plasma) has been shown to
contain many growth factors, such as platelet-derived growth factor (PDGF),
transforming growth factor beta (TGF-ß), vascular endothelial growth
factor (VEGF), epidermal growth factor (EGF), insulin-like growth factor
(IGF), etc. PRP has been successfully used in a variety of clinical applications
for improving both bony and soft tissue healing.
- Is it possible to activate platelets without triggering clotting?
For orthopedic surgical procedures, platelet rich plasma is generally made
to clot, using one of a number of different substances, so that the resulting
“gel” will stick to the injured cartilage better. The thinking is that when doing surgery on one joint, it is better to
concentrate the growth factors in that joint, rather than diluting the
platelet function throughout the body.3
For our purposes, since we want the platelets to stimulate growth factors
not only locally but also throughout the body, the PRP is activated by
exposing it to particular wavelengths of both visible and infrared light,
in a process called
- Why not use adipose tissue?
Adipose tissue has the highest concentration of mesenchymal stem cells
of any tissue in the body, even higher than bone marrow. Adipose-derived
stem cells also secrete higher amounts of healing growth factors (called
Adipose tissue is easily obtained through liposuction, generally from the
abdomen where most of us have more tissue than we really want. The number
of viable stem cells that can be collected does depend upon the type of
procedure used for harvesting them. These stem cells are also photoactivated so that their healing process
can begin immediately, with minimal inflammation in the joint.
- How is liposuction performed safely?
Liposuction is done by injecting a small volume of anesthetic solution
into the fatty tissues of the abdomen, and then removing around 4 tablespoons
of fat for processing.
When performed properly, removing only small amounts of fatty tissue, liposuction
is an extremely safe and surprisingly painless procedure.
- Why not use both platelets and adipose tissue?
Mesenchymal adipose-derived stem cells release extracellular vesicles.
Treatment with platelets stimulates the release of extracellular vesicles,
changes their protein composition and triggers the formation of blood
vessels – the initial step of wound healing. Platelet-rich plasma
has also been shown to enhance the proliferation and overall healing potential
of human adipose-derived stem cells.,
Using both PRP and MSC together seems like a win-win situation.
- How about using bone marrow?
For our purposes - using stem cell therapy to heal that which is not strong
enough to heal on its own - we use bone marrow without any further manipulation.
We simply filter it to remove any clumps or tiny bits of bone, activate
the stem cells by photoactivation, and re-infuse it immediately into the
patient’s blood stream or their unhealthy joint.
How well the bone marrow works depends on two factors – the patient’s
overall state of health and the number of stem cells that are injected.
We use a very special bone marrow harvesting needle which allows us to
harvest only bone marrow, without diluting it with peripheral blood as
happens using a standard bone marrow harvesting needle. We withdraw about
10 cc (2 teaspoons) of blood from the bone marrow.
- Why use platelets instead of bone marrow or adipose tissue?
Platelets contain significant amounts of key growth factors, like PDGF-AB
(platelet-derived growth factor AB), TGFb-1 (transforming growth factor
b-1) and VEGF (vascular endothelial growth factor), which are able to
stimulate cell proliferation (meaning increase in numbers), matrix remodeling
(meaning changing the composition of the fluid that surrounds and supports
cell growth) and angiogenesis (meaning growth of new blood vessels, which
the body uses like a supply line for repair of damaged tissues).
- Is stem cell therapy safe if I have had cancer?
Stem cells, in theory, can produce any type of cell within the body. We
are coming to realize that cancer is such a difficult disease to treat
because it is generated from its very own cancer stem cells which travel
in advance of the wave of expanding partially differentiated tumor cells.
So why don’t our own normal stem cells turn into cancer cells? What
keeps them in check?
We know that when we culture embryonic stem cells, they sometimes are unable
to turn off their growth and division genes. When normal stem cells are
cultured to increase their number artificially, sometimes the same thing happens.
If cancer is already present in the body, there is evidence from a mouse
study that normal stem cells can promote the growth and metastasis of tumors.
Is it any surprise that injecting stem cells which produce growth factors,
together with tumor cells, might cause tumor cells to grow? Mice do not
have exactly the same metabolism and genetics as humans, but if something
harms a mouse, I would be reluctant to use that same something on humans.
The real question is whether stem cells injected into a human being without
known cancer will potentially cause an unknown or very small cancer to grow.
We do not do stem cell therapy with patients who have had a diagnosis of
cancer. We do not KNOW that micrometastases will be activated, but we
are unwilling to take the chance.
We will do PRP therapy for painful arthritic joints in patients who have
had a history of cancer, as long as their currently painful joints are
not due to the cancer disease process, and as long as the patients no
longer have any evidence of active cancer in their bodies. It is very
important that the patient understands the potential (albeit remote) risk
of activation of cancer cells which are currently invisible to detection
in their bodies.
We cannot guarantee perfect safety, only that we will do our best to avoid
known potholes in the road of regenerative medicine.
If you are interested in exploring cell based therapy for your chronic
painful joint or chronic illness, call us to speak with our new patient
coordinator. She will schedule a free 15-minute phone consultation with
one of our practitioners who will be happy to discuss the pros and cons
of your particular case and to determine whether cell based therapy has
a good chance of helping your condition.
 Whitman DH, Berry RL, Green DM. (1997) Platelet gel: an autologous alternative
to fibrin glue with applications in oral and maxillofacial surgery.
J Oral Maxillofac Surg 1997; 55: 1294-1299.