Knee Osteoarthritis treatments – Prolotherapy Medical News
As research is being published on articular cartilage regeneration, it is becoming apparent that a combination of Prolotherapy, Platelet Rich Plasma (PRP) therapy, and Stem Cell Therapy is an effective treatment for cartilage regeneration in cases of knee osteoarthritis
Research for PRP and Stem Cell Therapy
Older tenets of medicine state that cartilage cannot be repaired. Now these tenets are being challenged in both human and animal studies. Researchers in Korea found that rabbits with osteoarthritis of the knees treated with Platelet Rich Plasma Injections showed cartilage regeneration in all severity of knee osteoarthritis. The cartilage regenerative power of PRP injection in moderate knee osteoarthritis was greater than that in mild or very mild osteoarthritis. In other words the worse degeneration of cartilage the better PRP worked. 1
- In addition to PRP, research is confirming Stem Cell Therapy has shown significant promise for the repair or regeneration of damaged cartilage: “mesenchymal stem cells (MSCs) have great potential owing to their ability to create a reparative environment.” 2
In other published research the combination of stem cells and PRP were shown safe, effective, and reduced pain and improved function in patients with knee osteoarthritis.3 Other research states, that although surgical and pharmaceutical interventions are currently available for treating osteoarthritis, restoration of normal cartilage function has been difficult to achieve. Bone marrow-derived ‘mesenchymal stem cells’ appear to be ideally suited for therapeutic use in cartilage regeneration.4
While Platelet Rich Plasma Therapy and Stem Cell Therapy are providing a lot of excitement in the orthopedic community, they are not always and necessarily the first line of treatment many Prolotherapy doctors suggest.
- In the Journal of Prolotherapy, research confirms articular cartilage regeneration in five patients with Osteoarthritis. Here is the summation: “Prolotherapy improved the pain and function in five knees with osteoarthritis. All five degenerated knees showed evidence of articular cartilage regeneration in their standard weight-bearing X-rays after Prolotherapy. It is suggested that before and after X-ray studies can be used to document the response of degenerated joints to Prolotherapy.”5
So how do doctors decide if Prolotherapy, Platelet Rich Plasma Therapy, or Stem Cell Therapy is the best course of treatment for a patient? The decision is made in the office following a physical examination and detailed patient history. Each chronic pain patient has an individual case with individual needs requiring an individual approach.
Knee Osteoarthritis treatment
PRP and Stem Cell Therapy for Cartilage Repair
A pilot study is one where a small number of patients are given a specific therapy. If the treatment works then the authors recommend future studies on larger amounts of patients. Doctors at Cairo University in Egypt performed a pilot study involving stem cells from the bone marrow of the patient receiving treatment. The stem cells were transplanted on a platelet-rich fibrin glue and used in cartilage defects of the patients. The results showed that this therapy helped heal articular cartilage defects in a small group of patients.6 Five patients with full-thickness femoral condyle articular cartilage defects were treated with placing platelet-rich fibrin glue into the lesions and then placing culture-expanded autologous bone marrow mesenchymal stem cells. MRI’s were done after twelve months. MRI of 3 patients at 12 months postoperatively revealed complete defect fill and complete surface congruity with native cartilage, whereas that of 2 patients showed incomplete congruity.
The clinical scores showed statistically significant improvement at both times. Two of the patients had repeat arthroscopy and both showed significant improvement, with one of the arthroscopies showing an almost completely healed articular cartilage. The authors concluded that “autologous bone marrow with mesenchymal stem cell transplantation on a platelet-rich fibrin glue as a cell scaffold may be an effective approach to promote the repair of articular cartilage defects of the knee in human patients.6”
Bone Marrow Growth Factors
“To me, this was a very good paper and worthy of reading”, says Ross Hauser, MD. “Again, though the doctors are orthopedic surgeons and want to do surgery on everything. Why not have a control group that received injected stem cells without any surgery? My thoughts are it would have worked anyway, because the body knows best.”
The authors noted that the platelet granules of platelets contain transforming growth factor (TGF-B1) and insulin growth factor-1 (IGF-1), which both stimulate cartilage regeneration. This was one of the main points as to why they chose platelets as a scaffold (something to work as a platform to rebuild tissue). Of course a scaffold would have to be surgically placed.
Bone marrow is full of IGF-1 and TGF-B1. 7,8
Just about any growth factor is available in ample amounts in bone marrow. Want some FBS, PDGF, VEGF, IGF-1, IL-8, BMP-4 and others, it will be found in bone marrow. How does Bone Marrow Prolotherapy compare to the therapy done in the study? Direct Bone Marrow Prolotherapy does not use a scaffold, rather the stem cells from the patient’s bone marrow are injected directly into the patient’s injury. When one does direct Bone Marrow Prolotherapy as stem cell therapy, you are letting the body produce what it needs. You are not making it. If the body needs chondrocytes, I suspect it will make them from the stem cells found in bone marrow. How? Well the way it normally does, by differentiating stem cells into chondrocytes. These newly made chondrocytes need nutrition from the joint fluid, so if the degenerated joint lacks joint fluid the aspirated bone that was injected into the joint will stimulate joint fluid production via the synoviocytes. Yes there are studies that show stem cells go all over synoviocytes and are found in abundance in the synovium.
So yes, this first study reviewed was a good one. Articular cartilage can definitely be regenerated, I just say we do it without surgical intervention.
Hyaluronic acid options
“In patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events.” 4
Scott Greenberg, MD says “we see many patients who have had Synvisc and Synvisc-One treatments, a commonly prescribed injection for osteoarthritis of the knee.”
Synvisc is an injection solution processed from rooster combs that attempts to act as the naturally occurring synovial fluid in the knee. The goal is to help prevent bone on bone complications for approximately six months.
Knee pain injections: Is Synvisc for you?
“In our practice we do not recommend Synvisc because we feel it is a temporary fix for knee problems caused by osteoarthritis and other degeneration”, adds Dr. Greenberg. “Even in the best case scenario – synvisc products are promoted as providing only up to six months pain relief.”
Research agrees that PRP may be a better option. “Plasma rich in growth factors showed superior short-term results when compared with hyaluronic acid in a randomized controlled trial, with a comparable safety profile, in alleviating symptoms of mild to moderate osteoarthritis of the knee.”5
Platelet Rich Plasma Therapy
Recent research highlights Platelet Rich Plasma Therapy’s effectiveness for knee osteoarthritis, as shown in MRI observations. Researchers like to use MRIs as a scientific means to quantify findings, it offsets the “observational” or empirical findings of what patients report. This factor adds an objective measure to the subjectivity of patient reports.
In a study entitled “Clinical and MRI Outcomes After Platelet-Rich Plasma Treatment for Knee Osteoarthritis,” researchers looked at PRP for knee osteoarthritis using an MRI as a baseline.5 They set out to investigate the effect of PRP on early knee osteoarthritis, using changes in MRI structural appearances as their method of change. This was a prospective cohort study (they followed people or cohorts with the same problem – knee osteoarthritis) for one year following PRP treatment.
The method of PRP treatment was a single 6-mL platelet-rich plasma injection. This was not similar to a comprehensive Prolotherapy treatment using PRP in that it was not used in a series of treatments, so it was less aggressive than PRP Prolotherapy. This treatment was given to 22 patients who had MRI confirmed early stage knee osteoarthritis. Fifteen were followed during the course of the study and examined at 1 week, then 3 months, 6 months and 12 months,. At the one year mark they received an MRI.
The patients reported that “pain scores significantly decreased, whereas functional and clinical scores increased at 6 months and 1 year from baseline.” However, qualitative MRIs demonstrated no change per compartment in at least 73% of cases at 1 year. Please see Prolotherapy and Platelet Rich Plasma Therapy used together as knee osteoarthritis treatment.
1. Kwon DR, Park GY, Lee SU. The effects of intra-articular platelet-rich plasma injection according to the severity of collagenase-induced knee osteoarthritis in a rabbit model. Ann Rehabil Med. 2012 Aug;36(4):458-65. Epub 2012 Aug 27.
1. Klett MJ, Frankovich R, Dervin GF, Stacey D. Impact of a surgical screening clinic for patients with knee osteoarthritis: a descriptive study. Clin J Sport Med. 2012 May;22(3):274-7.
2. Bulman SE, Barron V, Coleman CM, Barry F. Enhancing the Mesenchymal Stem Cell Therapeutic Response: Cell Localization and Support for Cartilage Repair. Tissue Eng Part B Rev. 2012 Sep 24. [Epub ahead of print]
3. Koh YG, Choi YJ. Infrapatellar fat pad-derived mesenchymal stem cell therapy for knee osteoarthritis. Knee. 2012 May 12. [Epub ahead of print]
4. Gupta PK, Das AK, Chullikana A, Majumdar AS. Mesenchymal stem cells for cartilage repair in osteoarthritis. Stem Cell Res Ther. 2012 Jul 9;3(4):25. [Epub ahead of print]
5. Hauser RA, Cukla JJ. Standard Clinical X-ray Studies Document Cartilage Regeneration in Five Degenerated Knees After Prolotherapy. Journal of Prolotherapy. 2009;1:22-28.
6. Haleem AM. The clinical use of human culture-expanded autologous bone marrow mesenchymal stem cells transplanted on platelet-rich fibrin glue in the treatment of articular cartilage defects: a pilot study and preliminary results.
7. Mishima Y. Chemotaxis of human articular chondrocytes to mesenchymal stem cells. Journal of Orthopedic Research. 2008;26:1407-1412.
8. Smiler D. Growth factors and gene expression of stem cells: bone marrow compared with peripheral blood. Basic and Clinical Research. 2010;19:229-240.
2. Hauser R. Prolotherapy just makes more sense for cartilage injuries than accelerating arthritis with arthroscopy. Journal of Prolotherapy. 2009;1(1):6-7.
3. Laupattarakasem W, et al. Arthroscopic debridement for knee osteoarthritis. Cochrane Database of Systematic Reviews. 2008, Issue 1. Art. No.: CD005118. DOI: 10.1002/14651858.CD005118.pub2.
4. Rutjes AWS, Jüni P, MD; da Costa BR, et al. Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review and Meta-analysis. Ann Intern Med. 2012 Jun 11. [Epub ahead of print]
5. Intra-articular hyaluronic acid injection: not for gonarthrosis. Prescrire Int. 2013 Oct;22(142):248-9.
4. Del Gaizo DJ, Della Valle CJ.Instability in primary total knee arthroplasty. Orthopedics. 2011 Sep 9;34(9):e519-21. doi: 10.3928/01477447-20110714-46.
5. Graichen H, Strauch M, Katzhammer T, Zichner L, von Eisenhart-Rothe R. Ligament instability in total knee arthroplasty–causal analysis. Orthopade. 2007 Jul;36(7):650, 652-6.
6. Halpern B, Chaudhury S, Rodeo SA, Hayter C, Bogner E, Potter HG, Nguyen J. Clinical and MRI Outcomes After Platelet-Rich Plasma Treatment for Knee Osteoarthritis. Clin J Sport Med. 2012 Dec 12. [Epub ahead of print]
7. Cellár R, Sokol D, Lacko M, et al. Magnetic resonance imaging in the diagnosis of intra-articular lesions of the knee. Acta Chir Orthop Traumatol Cech. 2012;79(3):249-54.