Regenerative Medicine at ARA

 One of the most mysterious aspects of medicine is healing. I always marvel at the change that happens sometimes overnight with a wound. How seemingly destroyed tissue organizes itself into healed tissue. All the intricate processes and collaborations that have to happen for not only local tissue to grow but also for nerves to re-grow into the area and blood vessels to organize and eventually mature. This is basically the focus of Regenerative Medicine. Mind blowing potential, reduced sometimes to reduction of wrinkles. Its similar to using advanced AI to tell you how to cook an omelet. Aside from that dilemma, for musculoskeletal applications, these procedures have been used for years. Unfortunately field has been disorganized since the beginning. Lack of coordinated effort to put scientific proof, multiple systems, protocols and processes for the same procedure creates even further confusion. In the future this field has a potential to find the cure for previously incurable diseases, like ALS, spinal cord injury, Parkinson’s disease as well as aging related processes like Osteoarthritis. Today, however, even using term “regenerative” is a bit premature, as with today's applications there is no proof of anything regenerating in human body that we can influence. However, there is enough data out there to safely say that applications used most commonly - PRP, PRF, MSCs, exosomes, amnion derived products - all are safe and very effective at reducing symptoms. Physiatrists are uniquely positioned to pioneer and lead the field in musculoskeletal applications of Regenerative Medicine. In fact, physiatrists coined phrases like “Non-operative Orthopedics” and introduced terms like “Orthobiologics.” This is not only because by default we treat chronic pain issues, but also because we see functional implications that are only possible if there is healing. So despite clear scientific data, we do have anecdotal (individual experience dictated) experience that compels us to go against the ruling given by FDA and continue providing these at times marvelous and miraculous treatments to the patients. We will continue giving you a disclaimer though about controversial and experimental nature of these treatments until we get better proof. Future applications of these in musculoskeletal system are endless: osteoarthritis, acute traumatic injuries, catastrophic injuries, high velocity trauma (whiplash syndrome, car accidents), overuse and repetitive trauma syndromes – carpal tunnel syndrome, tennis elbow, jumper’s knee, golfer’s elbow etc. These days, medical consensus remains unchanged – these highly controversial procedures, despite potential benefits, should not be used as a treatment, due to lack of evidence that these actually treat any condition. Dr. Chitchyan has been trained in performance of these highly advanced procedures. As with any other procedure he follows his mantra of three “R”s: Right procedure at the Right time performed on the Right patient has 100% chance of success. More so, full evaluation and correct diagnosis becomes more important to ensure that these highly controversial procedures are done for the appropriate indications. As with any other procedure these as well carry risks. In some cases, specific applications for specific reasons has gained enough popularity and level of evidence necessary to be recognized by scientific field as effective and safe and in rare cases these are even covered by Insurance carriers. For example, Tricare has granted provisional coverage approval for use of Platelet Rich Plasma in specific cases of Osteoarthritis of knees. There is still a long road ahead for these products to become daily reality. Until then, they will remain investigational. Here at American Rehabilitation Associates we stay on top of latest developments in the field of Regenerative Medicine. We use only equipment that has passed rigorous testing under FDA guidance to minimize any possible risks. It comes with significant expense; however, we cannot put a price on safety of our patients. If you are interested in learning more about this field of medicine, please contact us and we will be glad to share our knowledge with you!

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 It has been speculated that platelets are cornerstone of initiation of healing of injured tissues and getting high concentration of those to the area might promote healing. Isolation and concentration of platelets is usually done with centrifuge and sophisticated proprietary protocols, created by the manufacturers of PRP kits. Depending on manufacturer your physician may be able to isolate platelets that are pure without any mixing of other cells, or will have some white blood cells and some red blood cells mixed in it. Since there are different kits being used by different practitioners and some processes involve manual steps, not every PRP is created equal!

 

That's the theoretical basis that started this field of medicine. As an intervention, it is a very technically simple procedure. The difficult part is isolation of the platelets and understanding of which fractions of blood are useful at different times during the healing process and which might have adverse effect on healing. In the beginning the process was almost completely manual. Blood was collected and allowed to "settle". In fact, the rate of separation of still blood is a well known diagnostic measure we use today - Erythrocyte Sedimentation Rate. It measures how fast erythrocytes fall down to the bottom of measuring tube. As a diagnostic measure it is very useful in inflammatory conditions. The rate is dependent on many factors but we know that high concentration of certain proteins, white blood cells and platelets - all increased in inflammatory states - cause the erythrocytes to move faster. With centrifuge and advances in technology, the process of separation can happen much faster and on much larger scale. It is used to produce blood products used in the hospitals - packed red blood cells, packed platelets, fresh frozen plasma etc. Going back to the historic aspect of Regenerative Medicine, it is difficult to pinpoint as to who and when first noticed healing potential and who coined the phrase Regenerative Medicine. However, several although not direct references date back to old old ages. It has been well known that injection of whole milk under the skin of patients with certain STDs and thus causing systemic inflammatory response with high fever would cure the infection. Also the concept of increasing local inflammatory state by creating negative pressure on skin and causing mild injury to the tissues as well as causing temporary hyperemia as it is in using suction cups has been used for ages to aid in healing of various illnesses. Then came dry needling. As technology evolved doctors and healers alike started putting things into the area - dextrose being one of those. That is known as Prolotherapy. Eventually more sophisticated science focused people decided to connect the dots. That became what we know to be Regenerative Medicine today. It remains as nebulous as its history, marred by controversy and obscurity. As a physician when I first heard of using platelet rich plasma, I was about as sceptical as an ardent scientific sceptic should be. So it took me a long time to start incorporating this new technology into my practice. Even now, I am one of the most conservative practitioners as I strongly believe that overuse of this is exactly what caused most of the controversy surrounding the field.

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When it comes to healing, I try to simplify the process in my mind as well as describing it to the patients. I provide analogy with car accidents. As car accident happens, it disrupts traffic. Everything stops, nothing can get through except emergency vehicles. But first thing that has to happen - someone will have to alert (signal, call) the authorities. Once emergency vehicles arrive, they clean up the area, assess the damage to the road itself, repair damage to the road and then traffic can resume and things can go back to normal.

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Same process happens in our tissues after an injury, disrupting function of the area. First thing that happens is signaling - this is done by exposing signaling proteins on the injured cells. In fact most of interior cell structure is a signal on its own. It is foreign to our immune system as our immune cells has never encountered those before. Pain is another strong signal that allows your body to limit movements around injury to reduce functional burden on the area. 

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Signaling causes certain types of cells to migrate towards the injury site. These are our White Blood Cells - leukocytes and lymphocytes. They are the regulators of a lot of things. If leukocytes are like garbage disposals and will clean up the area, lymphocytes will be like armed guards going door to door and irradicating any harmful elements that may be in the damaged area.

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Once the clean up is complete, assessment begins. It is a function somewhat more mysterious and we know less about this process, including why certain injuries will heal with no issues, while others will get excessive scar tissue and some other ones will not heal at all creating gaps in tissues. 

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Based on that certain types of cells - those stem cells - will start migrating into the area and start the process of rebuilding.

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Of course reality is much more complicated and hopefully one day we will gain some knowledge into the inner workings of our body. This is an overly simplified way of looking into it but at least it allows me to understand few things. Our tendons, ligaments and cartilage don't have robust blood supply and are not very innervated. This is because they are "sparsely populated" - do not have many cells. So when injury to these structures happen, signaling proteins do not get exposed as much, no signaling happens really. So basically your body may not even recognize that there is an injury. So nothing happens - no rebuilding, no reaction. Or sometimes it is us who stop the process by taking certain medications. NSAIDS work by halting production pathway that creates very powerful signaling chemicals in our body. That's why they reduce fever and reduce inflammation. When you are sick with flu and have 104 fever, it's a good thing. But when a tendon is trying to signal and heal - not so much. If signaling does not happen - it might result in a situation that no healing happens.

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As your body resumes functioning after an injury, things start hurting. But Dr. C, you just said that there is little innervation there, so why am I hurting so much? Well I am glad you asked. I can't tell you here as it is so much off topic of PRP and one of my trade secrets that allows me to target pain generators so well. So that's a possible topic for another chapter on another website perhaps. 

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Fast forward years after original injury, the area hasn't healed, still irritates surrounding areas causing havoc on function. In my understanding of PRP, this is where Platelets come in handy. Platelets do several things in our body. First they carry around huge amounts of what we call growth factors. These are signaling proteins. So once activated, platelets expose those signaling proteins, somewhat replacing that function from injured tissue. This is particularly important if you look at the healing of gaps in tissues - skin for example filled with blood clot or what is known as scan - a whole lot of thrombocytes. Second they are integral part of formation of said blood clots and scabs. These structures fill gaps and trap any debris from entering your body. And third, they act as initial scaffolding that stem cells move in. 

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It makes sense now that getting platelets to where they are needed may kick start the healing process. But they need to be activated. Non-activated platelets are activated by sheer physical force or by attaching to injured cells or structures.  And depending on the damage we are trying to heal, we may need lots of platelets! Here comes PRP - concentrated and isolated army of activated platelets ready to do their f

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Section 1: Understanding Regenerative Medicine

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1.1 What is Regenerative Medicine?

• Definition and overview of regenerative medicine

• How regenerative medicine differs from traditional treatments

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1.2 Principles of Regenerative Medicine

• Exploring the fundamental principles of regenerative medicine

• Focus on tissue regeneration, cellular repair, and healing

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1.3 Types of Regenerative Therapies

• Introduction to various regenerative therapies: stem cell therapy, platelet-rich plasma (PRP), prolotherapy, exosome therapy, and more

• How each therapy works and its potential benefits

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Section 2: Applications of Regenerative Medicine

2.1 Orthopedic Conditions

• Regenerative medicine in the treatment of osteoarthritis

• Healing of ligament and tendon injuries with regenerative techniques

2.2 Sports Injuries

• Role of regenerative medicine in managing sports-related injuries

• Enhancing recovery and restoring function in athletes

2.3 Neurological Disorders

• Potential applications of regenerative medicine in neurological conditions such as stroke, spinal cord injury, and traumatic brain injury

• Promising research and current limitations

2.4 Chronic Pain Management

• Regenerative therapies for chronic pain conditions, including back pain, joint pain, and neuropathic pain

• Addressing the underlying causes and promoting healing

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Section 3: The Science Behind Regenerative Medicine

3.1 Stem Cells and Their Potential

• Explaining the role of stem cells in regenerative medicine

• Different types of stem cells and their sources

3.2 Platelet-Rich Plasma (PRP)

• Understanding PRP therapy and its applications

• How PRP promotes tissue healing and regeneration

3.3 Growth Factors and Cytokines

• Exploring the role of growth factors and cytokines in regenerative processes

• Harnessing their potential for healing and tissue repair

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Section 4: Safety, Efficacy, and Future Directions

4.1 Safety and Risks

• Addressing common safety concerns and misconceptions

• Discussing the current understanding of risks and potential side effects

4.2 Efficacy and Clinical Evidence

• Reviewing clinical studies and research supporting regenerative medicine treatments

• Assessing the effectiveness of different therapies in various conditions

4.3 Emerging Trends and Future Directions

• Exciting developments in regenerative medicine research and technology

• Predictions for the future of regenerative medicine and its potential impact on healthcare

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Section 5: The Process of Regenerative Medicine Treatments

5.1 Patient Evaluation and Consultation

• Explaining the initial assessment process for regenerative medicine treatments

• The importance of a comprehensive medical history and physical examination

5.2 Treatment Planning and Customization

• How regenerative medicine treatments are tailored to each patient's specific needs

• Considering factors such as the type and severity of the condition, age, overall health, and treatment goals

5.3 Administration Techniques

• Discussing different administration techniques for regenerative therapies, such as injections, infusions, or surgical procedures

• Explaining the rationale behind each approach and its suitability for specific conditions

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Section 6: Integrative Approaches to Regenerative Medicine

6.1 Rehabilitation and Physical Therapy

• Highlighting the crucial role of rehabilitation and physical therapy alongside regenerative medicine treatments

• How exercise, therapeutic modalities, and functional training complement the healing process

6.2 Nutritional Support

• Exploring the impact of nutrition on tissue healing and regeneration

• Discussing dietary recommendations and the potential role of supplements in supporting regenerative outcomes

6.3 Complementary Therapies

• Introduction to complementary therapies that can enhance the effectiveness of regenerative medicine, such as acupuncture, chiropractic care, or massage therapy

• Exploring their potential benefits and their integration into a comprehensive treatment plan

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Section 7: Choosing a Regenerative Medicine Provider

7.1 Qualifications and Expertise

• Factors to consider when selecting a regenerative medicine provider

• Assessing their qualifications, training, experience, and track record of success

7.2 Facility Accreditation and Safety Standards

• The importance of choosing a facility that adheres to strict safety protocols and maintains appropriate accreditation

• Understanding the measures in place to ensure patient safety during regenerative treatments

7.3 Patient Testimonials and Referrals

• Utilizing patient testimonials and referrals as a valuable resource in selecting a regenerative medicine provider

• Considering the experiences and outcomes of other patients when making a decision

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Section 8: Looking Ahead: Advancements and Future Potential

8.1 Current Research and Clinical Trials

• Highlighting ongoing research and clinical trials in the field of regenerative medicine

• Discussing their potential impact on future treatment options and outcomes

8.2 Emerging Technologies and Innovations

• Exploring cutting-edge technologies and innovations that may shape the future of regenerative medicine

• Examples include tissue engineering, gene therapies, or 3D bioprinting

8.3 Ethical Considerations and Regulation

• Addressing ethical considerations surrounding regenerative medicine, such as informed consent, patient autonomy, and responsible use of emerging technologies

• Discussing regulatory frameworks and guidelines governing regenerative medicine practices

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Conclusion: In this ultimate guide to regenerative medicine, we have explored the principles, applications, and potential of this transformative field. Armed with this knowledge, you are now equipped to make informed decisions, engage in discussions with healthcare providers, and explore the possibilities of regenerative medicine for yourself or your loved ones.

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We put it through so many stressful situations and imagine the miracle of it lasting as long as it does. In fact it lasts up to 10 times longer than your car! How is that possible? Simple - our bodies have the ability to adapt to changes. After a broken bone heals, it takes the same amount of time or longer to remodel, so it can withstand the stress. It is a slow deliberate process that allows for otherwise disorganized collagen fibers to align along the stress lines allowing for proper force acceptance. Now, if we put the stress on that bone at the wrong time under wrong direction - another fracture will surely happen. Muscles, tendons and ligaments are there to aligns and move things in desired motion at the same time maintaining appropriate force applications on our body. It is an intricate and very much so complicated process that moves along with precise sequence of events that starts with a thought... I am thinking about something as I type, and that thought is becoming a sentence in a language I am typing in, translated into movements of my fingers hitting the keys in a sequential pattern, without even looking at the keyboard. Unless I make a typo as I did hundred times already, then I hit the backspace button again and again and again until I get it right.

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Although amusing to think about it, you might wonder how is it that our body operates at this level of intricacy for as long as it does. It is not just because of remodeling, regeneration or any other re-process. But also due to redundancy. We have so much redundancy that no matter what cataclysmic process we put our body through, for most part it will not even skip a beat. The best example of that are our kidneys. Only 30% of one kidney is needed to maintain normal kidney function. So once a doctor diagnoses a person with chronic kidney disease, disease process is that far along. Same applies to our musculoskeletal system. Have you ever wonder if your muscles are really stronger than what they are? Yes, they are. A lot stronger! Strength of a muscle comes from number of muscle fibers and frequency of their contraction. Think of them as car engine. An engine that has 4 cylinders at 1000 rpm will produce less power than 6 same size cylinders at 1000 rpm. But the same 4 cylinder engine at 5000 rpm, undoubtedly will produce more power than the 6 cylinder engine at 1000 rpm. So our muscle power or strength comes from frequency that individual muscle fibers are firing and number of them that are firing. And we have hundreds and thousands of those muscle fibers firing. Imagine what would have happen if they were firing whenever and at whatever frequency they wanted. You don't have to imagine just look at an infant wobbling around. All that wobbling is however necessary for our nervous system to learn how to control our bodies and to reduce unnecessary movements. Because anything unnecessary equals energy wasted. And our bodies are very good at conserving energy. More on that later...

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Disclaimer: regenerative medicine is a rapidly evolving field, and new discoveries are being made regularly. Stay informed, engage in dialogue with healthcare professionals, and continue to explore the potential of regenerative medicine in transforming lives and improving outcomes.