Clinical Applications of Stem Cell Science AAPMR 2014 Victor Ibrahim, MD FAAPM&R Director, Performance & Musculoskeletal Regeneration Center Washington D.C.
Thank you!
Overview • • • •
Defining the Landscape Indications For Use Procedure Consideration Pearls for Practice
Terminology and Theory
Terminology (cont) Adipose Derived Stem Cells (ADSC) Mesenchymal Stem Cells (MSC) Mesenchymal Signaling Cells (MSC)
Stem Cell Theory: Mechanisms of Action 1) Tissue Specific Differentiation
2) Paracrine Effect Parekkadan, Biju, et al. "Immunomodulation of activated hepatic stellate cells by mesenchymal stem cells." Biochemical and biophysical research communications 363.2 (2007): 247-252.
Cell Therapy in History Till & McColloch Maksimov
1908
Thomson
1963
s
1998
Centino Atala
2007
2008
***
2013
Regeneration is a Natural Phenomenon
When to Consider Regenerative Medicine? Osteoarthritis: – – – –
Early onset (>65 years) Weight reduction Highly active individuals Surgical contraindications
When to Consider Regenerative Medicine? Tendon/Ligament Pathology: – – – – –
Maximized Rehabilitation Positive Diagnostic Block Limited time off work Surgical Contraindications
Relative Contra-indications 1. Cancer: active? Treated? 2. Infection: Lyme disease 3. Endocrine dysfunction 4. Centralized Pain Syndrome
Is the patient optimized? Physiologically
Mechanically
Labs/PE
Therapy/Bracing
Labs to Consider Men
Women CBC 2. CMP 3. 8AM Cortisol 4. Total and Free Testosterone 5. TSH, Free T4, Free T3 6. Vitamin D25 OH 7. DHEA-S 8. IGF-1 9. Prolactin 10. LH and FSH 11. Post-Menopause: Estradiol/Progesterone 12. 8AM Fasting Insulin Level 13. Lyme PCR/Titer 1.
CBC 2. CMP 3. 8AM Cortisol 4. Total and Free Testosterone 5. TSH, Free T4, Free T3 6. Vitamin D25 OH 7. DHEA-S 8. IGF-1 9. Prolactin 10. PSA For men over 40 11. 8AM Fasting Insulin Level 12. Lyme PCR/Titer 1.
Courtesy of Brian Shiple, D.O.
Sources of Regenerative Material
Common Regenerative Methods
Prolotherapy
Bone Marrow Cells
Autologous Blood Products
Fat Derived Cells
What is Platelet Rich Plasma? Inflammatory “Goop” Includes: Platelets, Fibroblasts, Growth Factors, Mesenchymal Stem Cells
Am J Sports Med November 2009 vol. 37 no. 11 2259-2272
Platelet Rich Plasma: Derivation
Questions about PRP Does concentration matter? ● Does RBC count matter? ● Does WBC count matter? ● How often? How much? ●
Bone Marrow Concentrate Cellular Goop: Includes: Nucleated Cells (Progenitor Cells)
Adipose Stem Cells Stromal Vascular Fraction: SVF Adipose Fluid Portion SVF
vs. Culture Expansion
FDA: Adipose Stem Cell Code of Federal Regulations (CFR) Title 21: Includes use of adipose stem cells “Currently, the recovery, processing, and implantation of autologous adipose tissue is considered by the FDA to be human cells, tissues, or cellular and tissue-based products.” Deborah L. Griffin Adipose Tissue Regulation in the United States Telegraft April 2013
Bone Marrow Concentrate Derivation
Equipment: Manual
Equipment: Drill
Patient Positioning
Anesthesia Pearls 1. Palpate/image PSIS 2. Lidocaine/Rupivocaine 3. More dense block with sodium bicarbonate 3. Consider oral sedation
Preparing Needles/Syringes 1. On sterile field prep two 30mL Heparin Solution (1,000 U/mL) 2. Rinse Jamshidi Needle AND syringes prior to needle insertion 3. Load syringes with 3mL Of Acid Citrate Dextrose Anticoagulant (ACD-A)
Jamshidi Needle Aspiration 1. Small incision for needle 2. Insert needle to bone contact 3. Advance between 3-5cm 4. Begin aspiration 4-10 mL 5. Rotate needle 90 degrees, continue to aspirate
Troubleshooting Aspiration 1. Pain with needle insertion 2. Negative aspiration a. Check depth b. Consider imaging c. Dislodge marrow with wire hook
Image Guidance: Ultrasound
PSIS
Image Guidance: Flouroscopic
Processing Cells 1. 30-60mL volume: 10% rule 2. Centrifuge at 3G (3000 RPM for standard system) 2. Approximately 12 minute spin cycle 3. Isolate buffy coat
Pearls for BMAC Harvesting 1. Consider sedation 2. Obtain vitals prior to aspiration 3. Steristrip over wound 4. Note harvesting site in medical record 5. Do not retap same site for 6 months
Post Procedure Care 1. Monitor site for infection 2. Cautious use of Tylenol 3. No swimming/bathing 24 hours 4. Recommend 4 weeks followup
Practical Applications
Is More Better? 1. BMAC + PRP 2. BMAC + PRP + HA 3. BMAC + PRP + Glucosamine + HA
Prospective, Randomized and Double-Blinded: Avascular Necrosis
WOMAC WOMAC
CD + BG 24 mo
45 patients
PAIN Pain CD+BG+BC Progression
Stem Cell Research & Therapy 2014, 5:115 doi:10.1186/scrt505 Published: 14 October 2014
Medications During Therapy 1. Avoid NSAID's in general 2. Short course of opioids for procedure pain 3. Blood thinning agent (Plavix, Effient, Brilinta, etc.)
Adjunct Therapy 1. Oral Supplements 2. Hyaluronic Acid 3. Prolotherapy (dextrose) 4. Glucosamine Injections 5. Ozone
Rehabilitation Protocol
Phase I: Acute Phase Post Procedure Day
Precautions
1-2
PWB
2-7
WBAT
Therapy Goals
Home Program
PROM
Consider Bracing
AROM
Closed Chain Program
Phase II: Functional Post Procedure Day 7-14
Precautions Therapy Goals
None
High Resistance/ Closed Chain
Home Program
Continue Closed Chain Program
Phase III: Maintenance Post Procedure Day
Precautions
14-21
None
21-28
None
Therapy Goals
Home Program
Functional Movement Patterns
Proprioception Exercises
Open Chain Agility
Long term HEP
Evolving Issues
Are Fat Pads Superior? 18 elderly patients with OA “Mesenchymal Stem Cells” Bone Marrow
Synovial Fluid
Moderate Chondrogenic Moderate Proliferation
Fewest Cells
SubQ
Hoffa's
Fastest Strongest Prolif. Chondrogenic Poorly Capacity Chondrogenic
Cells Tissues Organs. 2012;196(3):231-40. Epub 2012 Mar 20. Differences in Surface Marker Expression and Chondrogenic Potential among Various Tissue-Derived Mesenchymal Cells from Elderly Patients with Osteoarthritis. Alegre-Aguarón E, Desportes P, García-Álvarez F, Castiella T, Larrad L, Martínez-Lorenzo MJ.
Cell Survival
Do Stem Cells Survive?
Conclusion: 5% of the IA injected hASCs were detectable in the joint for the first month and 1.5% of hASCs engrafted on the longterm, at least 6 months. Toupet, Karine, et al. "Long‐term detection of human adipose derived mesenchymal stem cells after intra‐articular injection." Arthritis & Rheumatism (2013).
Do Cells Survive Anesthetics?
Conclusion: Lidocaine affected cell viability after 24 h, even when the cells were exposed for only 1 or 2 h. Apoptosis was not involved in lidocaine cytotoxicity. Regarding inflammation, no TNFα was produced, and lidocaine decreased the levels of IL-6 and MCP-1 in a dose-dependent manner. In contrast, adrenaline did not influence cell viability or cytokine secretions.
Girard, Anne-Claire, et al. "New Insights into Lidocaine and Adrenaline Effects on Human Adipose Stem Cells." Aesthetic plastic surgery 37.1 (2013): 144-152.
Factors for Cell Proliferation Donor age Type (white or brown adipose tissue) Location (subcutaneous or visceral) of the adipose tissue the harvesting procedure Culture conditions Plating density and media formulations
Mitchell JB, McIntosh K, Zvonic S et al. Immunophenotype of human adipose-derived cells: Temporal changes in stromal-associated and stem cell-associated markers. Stem Cells 2006; 24: 376–385.
Induction of Cells: Bone & Cartilage
β-glycerophosphate and 1α,25-dihydroxyvitamin D3 in PGA culture
Mahmoudifar N, Doran PM. Chondrogenic differentiation of human adipose-derived stem cells in polyglycolic acid mesh scaffolds under dynamic culture conditions. Biomaterials. 2010; 31: 3858–3867.
ADSC: Anti-Inflammatory & Chondroprotective Effects
Desando, Giovanna, et al. "Intra-articular delivery of adipose derived stromal cells attenuates osteoarthritis progression in an experimental rabbit model." Arthritis research & therapy 15.1 (2013): R22.
BMAC: Anti-Inflammatory & Chondroprotective Effects
Journal of Translational Medicine 2014, 12:157 doi:10.1186/1479-5876-12-157
Published: 3 June 2014
Clinical Trials in Human Medicine
Total Clinical Trials
Total: 96
Data from ClinicalTrials.gov
Regulations and Pearls for Success
FDA Jurisdiction 1. Boundaries unclear 2. “The agency does not regulate the practice of medicine” From About FDA 3. Human cells and tissues intended for human transplant are regulated by the FDA. The FDA maintains two levels of classifications for cells and tissues: 1) HCT/P 361 and 2) HCT/P 351.
Are Cells Drugs? 1. Autologous use of human tissue is not considered a drug (ie skin grafts, tendon transfers). 2. “Manipulated” tissue or cells ARE a drug
What does this mean? Cells become a drug when the intervention: “alters the MSCs’ relevant biological characteristics and is therefore more than minimal manipulation.” Circuit Court Judge Thomas Griffith DC Circuit of Appeals (2/4/2014)
Pearl: Contact BOM/FDA 1. To be sure you are in good standing with your protocol, contact local regulatory officials. 2. Be sure to send consent forms and protocol explanantions.
Pearl: Marketing 1. Be sure that patients are aware of FDA regulations 2. Consider a handbook for patients 3. Be sure consent form is clear regarding regulations
Cases In Regenerative Medicine
TENDON INJURY
BONE INJURY: Avascular Necrosis
Ibrahim, Victor, and Heather Dowling. "Platelet-rich plasma as a nonsurgical treatment option for osteonecrosis." PM&R 4.12 (2012): 1015-1019.
One Month Post PRP Treatment
MENISCAL DERANGEMENT
Medial Meniscus Treatment: Adipose Scaffold
Initial Exam
Week 5
Week 8
Thank you!
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