Weekly Education meeting 2020-06-22
Lots of questions and answers regarding regenerative medicine and hip pain.
-Can regenerative medicine help in hip arthritis?
-SI joint issues.
-How long does it take after treatment to see benefit?
-Treatment candidacy.
-Treating the contralateral side when you have arthritis on one side.
-Medications contraindications to treatment.
Okay Hello this is Siddharth Tambar from Chicago arthritis and Regenerative medicine. This is our weekly educational broadcast discussion that I have with my team. So we have a couple questions today. And these are questions that I get from, team members who are talking to patients in terms of what are they hearing, what are the concerns patients have.
So, a couple questions that came up. Number one is kind of an interesting one which is for the regenerative treatments, How well does it work if you have such bad hip arthritis that you need hip replacement? I think that was the question right Jackie? And it’s a great question because number one, there’s a, it’s worthwhile to understand that different locations, respond differently to treatment. So based on information that we have, from not only the Regenexx network registry but also from the overall literature, what we know is that hip patients will respond differently than knee patients. So someone that has like advanced knee arthritis can still respond quite well, someone who has advanced hip arthritis is less likely to respond well. What that means is that their chance of getting a good degree of pain relief and functional improvement is going to be harder than someone that has knee arthritis.
There’s probably a few reasons for that. Number one, knees are just built to handle a significant amount of damage and pain. So our classic knee patient that shows up will be someone that will come in saying, “I’ve had knee symptoms going on for like 10, 20 years”. Maybe they’ve had surgery, maybe they’ve had other injections and frequently they may not be ideal body weight and they have diabetes. And yet their response to treatment for what we do in terms of the regenerative medicine treatments is they’ll still on average get 60 to 65% improvement in pain or better like just knees can handle it.
Hips on the other hand, are a very different story. Our classic hip patient, is someone who’s actually in shape, is actually exercising, pretty regularly, and comes in saying “wow my hip has been hurting a lot progressively the last nine to 12 months”. And pretty quickly you find that they have very aggressive advanced arthritis. They’ve lost a range of motion. Biologically something else is going on. So an interesting study that came out a couple years ago, actually looked at hip arthritis patients and found that the ones that had more progressive arthritis, and worse outcomes, where folks that actually had significant dysfunction in the mesenchymal stem cells within the bone around the hip joint. So biologically there’s something different about hip patients compared to our knee patients.
So our typical hip patient, if they’re coming in with severe hip arthritis, where they’ve lost range of motion. They are going to be a very hard patient for us to treat. And frequently in that kind of case, I will recommend, if I’m convinced that their pain is coming from the hip joint, I’ll recommend that they actually go for hip replacement surgery. In the cases where patients in that scenario, want to avoid surgery and still want to try one of our regenerative treatments. Number one, I’d recommend bone marrow aspirate concentrate derived stem cells. Number two, they need to understand that their chance of getting a good average or better response let’s say 50% or better response in terms of treatment is going to be harder. That they may have a 30% chance of hitting that or better. They’re just a harder candidate.
Now with that said, there are different levels to hip arthritis or hip pain. A lot of times when people think of pain in one area, they’ll think of it as a x ray of what’s going on and say your pain is coming from that one arthritic joint, but in reality the human body works a bit differently than that. Meaning when you look at someone that has hip pain, there’s a series of different things that are causing problems that lead to pain and dysfunction, meaning it’s not just a joint. It can be the bone, which I’ll describe in a second, that can lead to hip pain. It can be ligaments, soft tissue structures, labrum. It can be a lot of other structures around the hip that are driving pain. The interesting thing is that it can be more than just hip pain though, it can be coming from the SI joint. The SI joint is essentially the joint between the pelvis and the hip that basically can cause pain in the back of the head in the buttock area, but it can also be pain, even in the lower back, that can then translate into pain in the hip.
So I’ll give a couple examples to that. So my mother, I recall my mother limping, when I was looking, when I was doing college, when I was interviewing for colleges. I remember at Brown University which is located I think in Rhode Island, Providence, Rhode Island. That is very hilly and that she was limping, as we were going from one building to the other is the first time that I noticed that maybe she had something wrong with her gait. I kind of forgotten about for about 20 years. And in my late 30s, I realized she was having more hip pain. On her imaging, you’ll see that she’s got some hip arthritis, but on her examination you realize that her pain is not necessarily coming from the hip joint. It’s actually coming from SI joint. So, when you talk to her, she’ll tell you, “oh yeah, I’ve had that pain in my hip since you were born.” And so what you realize is that the normal kind of experience of pregnancy was that her si joints got loosened up in order to accommodate the womb. And she’s basically had pain from her SI joint those translated into her hip for literally decades. So our approach in her case was we ended up doing PRP treatment into her, into her SI joint, SI ligaments. And the cover our bases, we treated some of those other tissues as well the hip joint in the lower back but it’s is really the SI joint, and she had a really good response to treatment to the point where her hip pain was significantly better, where she’s able to walk significantly more exercise regularly on a daily basis, she can do five K’s. And my mother is about 74, she’s 74 currently or 73 could becoming 74. And essentially, I’ll still treat her basically every two years for the last couple years, and that sort of keeps her tuned up for the next couple of years where she can keep on exercising. So someone that’s got hip pain, could be really coming from SI area. You can tell that based on partly examination, partly on description of pain, and some even imaging.
The thing about imaging is that imaging can sometimes lead you down the wrong path. Have another patient, I’m actually seeing him today for his left hip pain, but I recently saw him several years ago for right hip pain. What’s interesting was his right hip showed a lot of damage on his imaging at that time. And he actually had a hip replacement and he still had hip pain. So at that time before he saw me he actually saw an interventional pain doctor that did a diagnostic injection. where they injected numbing medication into his SI joint, and he had resolution of his hip pain. So again we treated that with PRP, and he did well for a few years. I’ll find out how he’s doing right now, today. But an example of where imaging doesn’t always lead to things, right when imaging can sometimes be tricky.
The last example, I saw a lady recently over telehealth, tele Med. where she was describing hip pain again. She’s in her late 70s. She came to me, because she’s a friend of family in California. So I had a relatively limited examination that I could do for, do you with her, but she’s got an X ray of her hip that shows very mild arthritis, and on her examination from what she could do over zoom, a zoom call you could tell that she can move her hip. She’s still a good range of motion but she would have discomfort in her hip, suggested that there is something going on in the hip joint that could be a problem. So what’s curious is her physicians where she was she lives in Palo Alto had tried an injection to the epidural space. She’s had multiple injections over the last 20 years, steroid injections into the epidural space in her lower back, which have given her pain relief in the lower back. They also then recently tried a injection into her lateral hip, the outside part of her hip because they thought could this be bursitis, and she didn’t get any benefit from that either. So for me I was, I was talking to her saying look your examine is suggesting one thing, your x rays don’t fit that you’ve had some other treatments there’s something that we’re missing here. so we ended up getting a hip MRI. And so her hip MRI ends up showing that she’s got some damage in the actual bone. She’s got some early stage of avascular necrosis. That’s relevant because the bone is what actually feeds the joint. So she’s got pain in her hip, because she’s got avascular, developing avascular necrosis an early stage of that. Realistically, she probably developed that because of all the steroid injections shes had over decades. And so, you know, it’s like she has hip pain that can be treated still non surgically because she doesn’t have bad hip arthritis yet. But if he doesn’t get treated that damage to the bone will eventually lead to bad hip arthritis. And so the right way to treat that is percutaneously, meaning with a needle based method, you kind of put the needle into the hip bone decompress it, and then you inject your own bone marrow derived stem cells that’ll actually help her out. If she does that, she’ll probably get done in California from from a colleague. But it’s another example where there’s layers of this, when somebody says “hey I’ve got hip pain that requires surgery.” Well, you need to look through those different kind of layers. And so you can still come to a smart decision, but realize that there’s sort of what we know about hip arthritis, and there’s really how you approach it to kind of sometimes get at what’s really causing pain. Does that make sense?
[Team] yes What’s the next question Jackie?
– [Jackie] How Long Does it take,
– Recovery after the procedure to see differences?
Right, so great question. So, when you look at, so the question was how long does it take after a regenerative treatment process to see a response. So, this is very different than let’s say a steroid injection or a numbing injection. Steroid injection you’ll get relief after like one or two days, it’ll last for weeks to a couple of months, and then it progressively wears off. It’s different than let’s say a platelet or bone marrow stem cell injection, where you’ll have more inflammation for the first few days and even stiffness for the first couple of weeks, and then progressively improvement that starting at that four to six week mark. That’ll then kind of progressively improve for the next three to six months. In PRP there’s data that shows you’ll get that improvement up to six months in some cases even up to 12 months. What I generally tell people as expect improvement at the four to six week mark let we reconnect at the at the eight week mark see where you are. And if at some point over the next several months you’re starting to plateau and you’re not at your goal, then let’s repeat treatment. However, if you’re still improving expect there to be a continued slow improvement. And the nice thing is, as that improvement occurs, you’re able to then start to do more physical activity, which then provides more support for the joint that’s been treated. And then, that adds on to treatment improvement as well.
Jackie you had one more question?
– [Jackie] Yes, can they still proceed with the procedure if they are anemic?
– Right, so the question is about anemia. So, if you’re anemic it depends on how anemic they are, realistically so if you are, the guidelines that we have are if you are mildly to moderately anemic we reduce the amount of bone marrow that we’ll draw out or the amount of blood that will draw out from a safety standpoint. So part of it depends on, you know why are they anemic? Meaning if somebody is anemic because they have let’s say, leukemia or lymphoma, well that’s not really the kind of person that you necessarily want to treat with these kind of treatments, you’d prefer that they actually get their underlying condition treated first, before they proceed with treatment. On the other hand if they’re anemic because let’s say, they’re B12 deficient. Okay, well you just reduce the amount of blood or marrow that you take out, you should obviously be trying to treat the anemia as well. Mainly because from an overall health standpoint you want to improve that also. If they’re anemic because they’re on meds. Maybe it would make sense for them to actually do something to manage your meds first before they actually proceed with treatment. But at the time, obviously you kind of adjust the amount of blood or marrow that you take out. Does that make sense?
– [Jackie] Yes
To me the big thing is, why, right, like are they anemic because there’s something actively going on. That should be addressed before they actually proceed with treatment. You know reality is if somebody is anemic because they’re severely B12 deficient, if you corrected that they may just feel better on their own, right, they may not actually need to proceed with treatment. So sometimes understanding the Why goes a long way to, you know before you make a decision. Other questions.
– [Member 1] When someone comes to you with hip arthritis in the right hip, how often do you notice the other hip have damage, and do you ever recommend treatment, what kind of treatment?
There’s so many layers to that. So the question is when someone comes with hip arthritis on one side, how often do you see problems on the other side. And would you prophylactically treat that. That’s an interesting question because if you’re getting if you if you have someone that has severe arthritis in one hip, That may just need to be treated separately surgically anyway, Right? But then you sort of put attention to the other side where you’re saying well look something’s developing over there, maybe it would still make sense to treat that after the other hip has been treated. I think that’s one way to think of it. The other way to think of it is if somebody has let’s say mild to moderate hip arthritis that can still succeed from our treatments. Should you also be thinking about the other hip, you should certainly be thinking about it from a physical therapy, posture related standpoint, weight reduction standpoint. I think if you’re treating one hip with let’s say bone marrow derived cells, if they’re other hip is milder, they may benefit from just platelets. Alternatively, understand that they may have pain on the other side, not because of the hip joint but maybe from the lower back. So, if their lower back or SI areas is problematic, perhaps treating that at the same time would actually help the other side as well. So again it depends on why the other side is problematic, what stage is it, and is there something else going on the lower back that needs to be addressed.
– Thank you
-Lilia.
-[Lilia] what make a candidate not a good candidate for treatment?
Yeah. So what makes somebody a bad candidate for treatment. I think of a few different things. Number one is obviously what’s the severity of the pathology, but again, understand, an advanced arthritic knee can still respond well to pain relief. Advanced hip arthritis, not as much so part of it depends on which area, what degree of pathology. Number two is what about their otherwise overall health. You take someone that’s like a bad diabetic, who is poorly controlled that’s got bad metabolic syndrome, that kind of person is a challenging candidate for any treatment that humans can do, right, just because they are overall, just not a healthy person. On the other hand if you take someone that’s a diabetic, but they’ve actually put in the work the effort. Maybe they’re on meds, but really good diet, they’re exercising they’re doing everything they can. That’s kind of someone who’s put in a lot of effort, where maybe they’re controlling things where maybe they’re actually an okay candidate still that despite that other diagnosis they’ve done so much to help themselves out where they can still benefit. Then I think the other thing that I think of is what other meds they on. Are they on meds that can actually be challenging in terms of response to treatment. Because there are some meds that can actually do that. And then, to me, the the other kind of thing is what is also their expectations for treatment. When I talk to patients, if they’re fixated on let’s say, improving an imaging finding and not as much pain relief and functional improvement, You know, like maybe they’ve got the wrong expectations for treatment. That they may be a good candidate based on some of the other objective medical factors. Maybe they’ve got the wrong expectations and so having that conversation is important. So it’s going vary from person to person based on pathology, or their medical issues, maybe medications, and then also their expectations like from a professional standpoint, it’s sort of sussing out all those details to align our expectations and what we can achieve.
– [Member 2] Can you me an example of medications?
Yeah it’s an interesting one because the Regenexx lab in Colorado has really looked at what medications are harmful for mesenchymal stem cells in the lab setting. there’s so many different meds, like it’s it’s most meds, realistically. Your body’s not used to being exposed to that, it’s not evolutionary been developed for that. So, it’s tricky because if you can get people to limit certain non essential meds, then they should try to limit that. Let’s say anti inflammatory meds for pain. Okay, let’s try to limit that. Some blood pressure meds, maybe they can do stuff like that but it’s a little bit hard, right. The one that’s most relevant to me that I see are patients that have autoimmune issues, who may be on steroids, some other immunosuppressants. And what I try to guide them is, can you minimize the steroids as much as possible. But if you need that other medication to maintain your overall immune health, then I think you stay on that. It’s tricky. In my own experience, even when patients are on those meds, in theory you can tell them that maybe that’s not ideal for your treatment, but in my experience, they still do fine, in terms of treatment, but in theory that might be something that could be a limiting factor to treatment. But in reality, if they stopped those meds, if their overall condition is then active, that makes them a much harder medical candidate at that point. So, my personal take is, if someone’s got an overall medical issue that’s still active, optimize that in whatever way you can, ideally if you could do that non medication wise, which is diet and exercise or supplements. but in those people that still need meds, if that keeps them optimized and the best at their health, then that’s the best they can be in terms of a candidate. And just stopping those meds is not a smart thing you need to just take that into consideration that that may limit the effectiveness, but at least those meds have optimized your ability to live. What else.
So good questions you guys came prepared. Thank you.
-[Member] Thank you.
Yeah. Okay, good. Well, thank you very much everyone, and until next week, look forward to talking then. Be well and live well. Bye bye.
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***About this video***
In this video Siddharth Tambar MD from Chicago Arthritis and Regenerative Medicine discusses regenerative medicine treatment options for the hip, and related issues.