Although it may sound like a medical procedure that is brand new or ‘experimental’, Stem Cell therapy has actually been in use for several years. Rheumatology Therapeutics Medical Center (RTMC) has been an innovator in the use of Platelet Rich Plasma (PRP) and Mesenchymal Stem Cell (MSC) therapy since 2010.  We have chosen to be innovators because we believe that the future of arthritis and orthopedic therapy will be application of stem cells and not more surgery or medications.  Just like medications have been developed to slow progression of inflammation in joints, these new therapies will begin to slow cartilage degeneration, chronic tendon and ligament damage, and meniscal defects.  Many famous athletes and celebrities have had access to these therapies for years and now the average patient can not only benefit from them but also afford the cost of the procedures.

We began with Platelet Rich Plasma (PRP) in 2010 after hearing of the amazing anecdotal results in athletes.  After training and extensive research on the topic we began to use the procedure in for tendonitis, enthisitis, arthritis, rotator cuff tears, and meniscal injury. We also use it in some of our chronic arthritis and even severe osteoarthritis patients.  After seeing excellent results, we have continued to expand its use and have now made it a core component of treatment in our practice.

In 2014 we also began to incorporate proprietary techniques that give very large yields of Mesenchymal Stem Cell (MSC) and use them, along with the PRP, to get even better and longer lasting results.  These stem cells have been shown in studies of both animals and humans to decrease pain, improve function, improve quality of life, and in some cases slow or reverse tissue damage.  We are also careful not to oversell these procedures since they do not work in everyone and research into their benefit is ongoing.

Some MSC’s do exist in PRP but are more prevalent in Bone Marrow Aspirate (BMA) and even more so in Adipose Derived Stem Cells (ADC).  The Adipose Derived Stem Cells are particularly numerous and suited to be used for large joint injections such as the knee, hip, and shoulder.

If you are interested in moving forward with these procedures, our doctors will examine you, review and assess available labs, review your radiology reports to determine if you are a candidate.  If so, then they will work together with you to customize a treatment plan for the best type of Stem Cell Therapy to help your medical condition.

More information on Platelet Rich Plasma (PRP): See the PRP tab

The body’s first response to soft tissue injury of any organ is to deliver platelets to the damaged site. The platelets first cause local clotting then release growth and healing factors to initiate repair and attract the assistance of stem cells to help repair the tissue.  PRP’s intensifies the natural healing process by delivering a very high concentration of platelets, directly into the area in need. Peripheral blood concentrate in the PRP also contains 10,000-20,000 MSCs that then stick to the damaged tissue and begin the scarring or regenerative process.

Compared to Cortisone or Hyaluronic Acid injections, PRP/Stem Cell injection has a lower risk of complications and more long term benefits. Because the injections may actually heal the affected areas, the relief from tendonitis, bursitis, or osteoarthritis pain can last for an extended period of time. This therapy can also provide long-term relief from hip pain, knee pain, elbow pain, foot pain, and other pain caused by inflamed connective tissue.

There may be a few days of more pain following a PRP/Stem Cell injection but improvement is typically noticeable after a few weeks, and the pain relief gradually increases as the tissue is repaired over the next few months. Since the tissue is drawn from the patient’s own body, there is almost no risk of rejection from this procedure.  There is very low risk of infection when any needle is inserted into the skin and or the injection site.  There may also be some bleeding or bruising after the procedure.  Infection with PRP/Stem Cell injection is very rare but possible.

Types of Stem Cell injections that we offer:

• Bone Marrow Aspirate (BMA):

Bone marrow concentrate contains 50,000-100,000 Mesenchymal Stem Cells (MSCs).  It is derived from bone marrow in your pelvic bone and can be very beneficial to augment the healing power of PRP.  The bone marrow is a central compartment in all of your bones that produces red blood cells, white blood cells, and platelets.  It also has a large concentration of hematopoietic stem cells.  These specialized stem cells are responsible for creating blood vessels.  It can help to provide stem cells that not only have the potential to help tissue damage but may increase blood vessel formation in the healing tissue.

Bone Marrow Aspirate extraction procedure:

Bone Marrow stem cells are collected by aspirating bone marrow from the posterior iliac crest.  There is usually minimal discomfort with the bone marrow aspirate, as the area is well anesthetized with a local anesthetic.  All instruments are coated with heparin to prevent clotting and the procedure is conducted in a sterile area to prevent contamination and infection.  A needle is inserted into the bone area by tapping with a small gavel.  About 2oz (60cc) of bone marrow aspirate is then suctioned with a manual syringe and then filtered to get rid of any clots or small fragments. After filtration is complete the bone marrow aspirate concentrate (BMAC) is placed in a centrifuge to be spun for separation of stem cells. This final concentrate is then injected in the desired area and followed closely by PRP aspirate which is prepared at the same time.

• Adipose Derived Stem Cells (ADC)

Adipose concentrate contain 100-150 million stem cells, which is 2000 times more Mesenchymal Stem Cells (MSCs) then Bone Marrow Aspirate (BMA).  It is by far the best source of MSCs available in an office setting.  These cells can differentiate into many different types of tissue including cartilage, tendon, ligaments, bone, nerve and fibrous connective tissues.  ADSC concentrate derived directly from your own fatty tissue that the doctor will remove from your abdominal or flank area the same day.  The high concentration of MSCs in ADC is used to augment the healing power of PRP by greatly increasing the number of stem cells available for healing damaged tissue.

In addition, adipose derived concentrate also contains cytokines (helper molecules) that augment tissue regeneration:

• HGF (Hepatocyte growth factor), which has a major role in organ regeneration and wound healing.
• VEGF (Vascular endothelial growth factor), which stimulates growth of new blood vessels to help repair tissue
• PGF (Platelet growth factor), which encourages new vessel and tissue formation after damage.
• TGF (Transforming growth factor), which causes cellular proliferation and differentiation

Adipose Derived Stem Cell extraction procedure:

Fat compartments are a very rich source of stem cells, specifically mesenchymal stem cells (MSCs). The procedure is a version of liposuction but less invasive, since only a small amount of aspirate is needed.   First a blunt tipped needle is place in either the stomach or flank area. The area is then anesthetized with lidocaine and injected with normal saline for better extraction of the adipose cells. The blunt needle is then attached to a negative pressurized syringe for manual suctioning. The needle is placed just below the skin and motioned in and out in a fan pattern. Once the adipose cells have been extracted they will be set aside to allow separation. Once the separation has occurred, the layer which contains the adipose and stem cells will be washed and spun using.  This final concentrate is then injected in the desired area and followed closely by PRP aspirate which is prepared at the same time.

Total Procedure Time Frame:

PRP injections only: the time frame of the procedure will be 45-60 minutes.

Adipose or Bone Marrow Aspirate: allow approximately 1-2 hours for the entire procedure, depending on which components you choose with your doctor

Important to Remember

This treatment is not to be considered an overnight cure that will yield immediate results. In fact, you will likely have more pain for the first few days.  Stem cell therapy is a repair process, and it may take weeks or months until you experience the final results. The repair may take 2-3 months, but improvement is typically noted before then. Various factors such as age, physical activity levels, nutrition, and smoking history may affect an individual’s response and rate of healing.  Stem cell therapy will not grow you a new joint or create a new tendon.  It is intended for pain relief, heal frayed tendons and ligaments, and increased patient comfort.  It may also delay or entirely eliminate the need for surgery.

What to Expect Before Your Procedure

If you are currently taking anti-inflammatory medications such as Motrin, Advil, Aleve, Celebrex, Voltaren, please discontinue them 2 days prior to treatment as well as 3 days after each procedure. If you are taking 81 mg or less of aspirin you may continue doing so. You may take your other prescription medications as you normally would.   Please, DO NOT discontinue or alter your routine medications without consulting us or your primary doctor. If you have any questions or concerns, please contact our office.

Follow your normal daily routine on procedure day. Make sure to drink plenty of water (eight to ten 8oz glasses) 24 hours prior to your appointment, and eat a proper meal. It may be helpful to bring some light snacks with you as you may need to wait 30 minutes for stem cell  preparation . No fasting is required on this day, and it is not advised.

What to Expect After your Procedure

The after care is NOT comparable to a major surgery but we would like to take all precautions to ensure your comfort.  Since there may be some discomfort in the joint, after the procedure, we suggest that you arrange for a friend or a family member to drive you home.  You may also be given a prescription for pain medications and antibiotics, if needed.

You will be numb in the area for approximately 2 hours after the procedure. While the area is still numb, please refrain from any strenuous activities.

• After the local anesthetic wears off, you may resume normal activities as tolerated.
• We suggest that you refrain from strenuous exercise of the injected area for a few days following the procedure.
• You will experience some pain and soreness for 2-5 days. The initial inflammatory phase may last up to 7 days but should subside gradually.
• Anti-inflammatory medications can be used beginning 2-3 days after treatment. You may use Tylenol and/or ice (30 minutes on, 2 hours off) if you experience soreness. Repeat as needed.  You may also apply a Lidocaine patch if needed.  These patches are applied for 12hr but then need to be removed for 6hrs before placing another or they will stop working. Only if you have severe pain then you may be prescribed a stronger pain medication by your doctor.  Only use these sparingly and per instructions of the pill bottle.
• While the area is healing, you may experience the “Roller Coaster Syndrome”; where you feel great one day and some return of pain the next. This is a normal part of the healing process. However, if you experience any excessive pain or swelling, or have any concerns, do not hesitate to contact our office.
• If you have fevers or suspect an infection in the extraction site or the injection site please contact our office for instructions.
• If provided antibiotics with your procedure, please complete your antibiotics to prevent any infection and keep the area of insertion/extraction clean with your basic soap and water.

Comparison of the Stem Techniques Used in our Office

NeuroMenda™ is a proprietary nontoxic vitamin infused therapy used to relieve neuropathic pain. It is individually compounded in our office as is viewed as safe by the FDA[1]. Our doctors use it to safely help many disorders that are due to peripheral nerve spasm and pain syndromes. Examples of where NeuroMenda™ injections can be safe and effective include:

• Neck pain
• Low back pain
• Post-surgical pain
• Chronic pain after Joint Replacements
• Chemotherapy induced Neuropathy
• Chronic Headaches
• RSD/Regional Pain Syndrome
• Leg and Lower Extremity Pain
• Morton’s Neuroma
• Nocturnal Leg Cramps
• Knee Pain
• Shoulder pain
• Achilles Tendinopathy

The treatment consists of a series of injections targeting painful and sensitive nerves. The procedure is safe and the effect is immediate. The effect may last for a period of four hours to several days. After this the pain may return, but usually much less than before. Repeat weekly treatments will steadily reduce the overall pain and allow return of full function.
The average number of treatments required for most conditions is 5-7. Success rates vary but in most cases patients experience 70-100% relief, depending on the condition.
Join our many happy patients that are out of pain and active again.
Please call the office for an appointment to see if you are a candidate 818-996-4077.

[1] This is based on the GRAS (Generally Recognized As Safe) designation of the FDA (www.fda.gov).

Energy BOOST IV: These are IV solutions, specifically tailored to individual patients, that can help increase energy, promote healing, improve cognitive function and decrease muscle cramps. We mix each dose specific to each patient based on their other medical issues, their medical complaints and other medications that they take. Some ingredients that may be included are:

• B12
• Vit C
• B-Complex
• Glutathione
• Magnesium
• Biotin
• CQ10

Other Innovative Techniques used at RTMC

• Prolotherapy:

Prolotherapy uses local injections of hypertonic dextrose (highly concentrated sugar).  It has been used for many years with almost no side effects and is used to trigger the body’s own healing response by irritating healthy tissue and creating a local inflammatory.  It requires repeat injections and the healing takes about a week and peaks at 4-6 weeks post injection.  Prolotherapy may be effective in sprain injuries, repetitive tendon or ligament injuries, and muscle stains.  It can also be used in treating back and neck pain.

Treatment may require between 3-4 sessions every 4-6 weeks to achieving the desired effect. There may be a moderate amount of soreness associated with these treatments and patients are recommended to discontinue anti-inflammatory medications during the course of treatment.

• Trigger injections:

Trigger injection are local muscle injections that combine a muscle relaxant, pain medication and anti-inflammatory medication.  These are very effective in helping acute and chronic muscle spasms in the neck and low back.  The relief is immediate and often long lasting.  These can be repeated monthly and have a very low side effect risk.  These are commonly done in doctors’ offices but few doctors understand how to place them correctly for maximum pain relief.  These are helpful in Fibromyalgia as well as in a host of neurologic and orthopedic spinal diseases.

• Homeopathic Trigger/Joint Injections:

This technique uses a pain medication combined with several well-known, safe, and studied homeopathic medications.

• TThe combination used to inject joints is called Traumeel/Zeel. Traumeel and Zeel injection solutions have been available globally for more than 60 years to help manage the pain of osteoarthritis. These are very popular throughout Europe but especially used in Germany.
• The combination used for trigger injections is called Traumeel/Spascupreel

• Hyaluronic Acid Injections:

There are many of these HA preparations.  These include Supartz, Synvisc, Synvisc-One, Hyalgan, Euflexxa, Orthovisc. (Euflexxa-has double x).  We can use any of these but prefer Supartz and Euflexxa due to their low side effect risks.  Supartz is a highly purified organic avian sourced HA.  Euflexxa is a bioengineered highly purified but non-avian-derived HA that can even be used in patients who have an allergy to chicken or feathers.  These each require 3-5weekly injections and can only be used in the knee since studies do not support use in other joints.  There are many studies showing that these can be effective for pain relief, improve joint function, reduce use of medications such as NSAIDS and Tylenol, and delay joint replacement surgery.  The effect of these injects can last 6-12months, at which time the series of injections may need to be repeated.

• Combined Injections with Homeopathics, Pain medications, Cortisone, Anti-Inflammatories or Hyaluronic Acid:

There are a number of possible combinations of these agents.  At this point we do not mix any of them with stem cell therapy or PRP since they can damage the MSC’s and cause platelets to burst.  However, we can combine many of the above injections such as HA and cortisone, Homeopathics with HA or Pain medications etc.  It is between you and your doctor to choose the best combination based on your medical problem and your other health concerns.

• Human amnion/chorion membrane Injections: 

AmnioFix is hydrolyzed micronized amniotic membrane.   AmnioFix contains 13 powerful growth factors.  Amniotic Membrane has been used in wound healing for many years and is now being used in joint arthritis, achilles tendonitis and plantar tendonitis. It is also used over wounds that are not healing, as with burn victims, to grow new tissue.  AmnioFix is pre-packaged and injected, using ultrasound guidance, to exactly the place of damage. This begins to jump start and boost the healing response so joints function better with less inflammation and less pain.  It also promotes healing of local tendons and ligaments.

• Nutritional Medicine:

Medical foods:  These are a new category of medications that are designated as GRAS (Generally Regarded As Safe) by the FDA and are made from natural ingredients such as micronutrients, amino acids, and food supplements.  They are, by prescription only, and can be used to improve sleep, energy, pain control, depression, osteoporosis, and osteoarthritis.

Energy BOOST IV: These are Intravenous solutions, specifically tailored to individual patients, that can help increase energy, promote healing, improve cognitive function and decrease muscle cramps.

Micronutrient therapy (iron, cobalt, copper, iodine and zinc):  These Intravenous infusions are specifically formulated for patients who have nutritional deficiencies or have had gastric or intestinal bypass surgeries.

Vit D IM high dose:  This is a process to deliver high doses of Vit D to patients with Osteoporosis, Vit D malabsorption or intolerance to oral Vit D.

Private label supplements: In order to help our patients improve their health we have contracted with a manufacturer of high grade and pure supplements to provide them by mail to our patients at a discounted rate.

• Sleep/Fitness:

Fitness and Sleep Tracker: In an attempt to promote healthy bones and joints, we have fitness trackers that we supply to our patients.  The fitness bands give us an idea of your activity levels and sleep quality.  This will help us access what treatments are working for you and which ones need to be changed.  This is a time intensive service and requires special visits with our doctors and fitness trainers.

Sleep studies: This is a new type of unintrusive sleep monitor system that is done in the comfort of your home and often negates the need to go to an overnight sleep lab.  This procedure is covered by most insurance plans and provides our doctors with acute information on the quality of your sleep, the length of your sleep and if you have sleep apnea.

• Fatigue Diagnosis/Treatment:

Energy BOOST IV: These are Intravenous solutions, specifically tailored to individual patients, that can help increase energy, promote healing, improve cognitive function and decrease muscle cramps.

• Genetic Testing– a way personalize medicine to your genetic profile
• Compounded Creams
• Ozone knee and trigger injections
• Biofeedback
• IVIG or IM IVIG or Gammastan: a way to boost you immune system to prevent recurrent infections and keep you healthy
• Full Infectious Work Up: A comprehensive laboratory panel is the best way to rule out infectious causes for Chronic Fatigue, Fibromyalgia or Arthritic disease.