| 1 | Peter Attia MD | Exploring the utility of stem cell therapy | Peter Attia & Adam Cohen | 58671 | 957 | 214 | 46.1 | negative | 16:55 | Where do stem cells play a role here? Now we're going to talk about stem cells through all of these joints, but we might as well start here. When I hear that the tendons of those muscles and those muscles themselves are going to weaken, when I hear that my cartilage is going to weaken, when I hear that the, you know, the osseus structure of the bone is going to weaken, all of these things make me wish. I could just have newer and younger cells there. Right. So what do we know about the utility of stem cell therapy here? What's the state of the art today? Right. So, you know, this is a, this is a great conversation. And there's a lot of layers to this conversation because there's, you know, the dark side and the bright side of this. The, you know, we talk about ortho-biologics or biologics in general. Basically, biologics, it's a, it's a class of therapies that are using your own natural resources to promote healing. So you're using a biologic product to encourage healing of diseased or injured tissue. So the most commonly used ones are blood, specifically platelets, bone marrow, bone marrow aspirate concentratus called, and also fat. So if we sort of go through those three, just to start there, the, for PRP, what are we doing? So we take your, platelet rich plasma. Platelet rich plasma. We take your blood, we draw it, and we take it down the hall, and we spin it in a centrifuge. And the centrifuge machine will separate out the different elements of the blood based on the density of those elements. So after you're done spinning it, you have a layer called the plasma layer, which is rich in plasma and platelets. And it separates out the red blood cells and a lot of the white blood cells. Now you could spin it twice, you could do two spin technique, you can spin it so that you're keeping some of the white blood cells. So we've categorized it into leukocyte rich PRP and leukocyte poor PRP. And this is a very simplified way that we think about it right now. And there's certainly, if we fast forward 10 years from now, this will be a ridiculous conversation. Because we just are sort of in our infancy of understanding what we're doing here. So the principle is we take those platelets, which are involved in healing. We know this because if you cut yourself, the first thing that happens is the platelets come to the surface to form a blood clot and to form a scar and then you heal. So platelets are associated with an incredible amount of growth factors and healing factors, including the 800 to 1,000 proteins within the plasma. And you inject that into tendon, a joint with arthritis, muscle, and see what happens. So the problem is that as a physician, you are allowed to do that procedure, right? So there's no, there's no rule that can't say that anybody comes in and they say, I have this injury. Can I have PR, can I have stem cells? And you say, oh, sure, let me give you PRP and I spin it and I inject it. So, but what is the actual science say about what's actually working? And what we've learned is that it works for some things pretty decently and other things not well at all. And we can only go by our randomized controlled trials and systematic reviews of randomized controlled trials to find out what seems to work. So what are the, what are those best case scenarios? So tennis elbow seems to work with PRP. There's good data to suggest, like tier one data, maybe tier two data that suggests that it works for tennis elbow. It works pretty decently for gluteous medius tears. And for tendons, that's about it. Some will argue maybe in the hamstring tendon it works, but I'm not convinced. And just to be sure, are you talking specifically about PRP or are you talking about the broader umbrella of stem cells? broader umbrella of stem cells don't seem to work. And I think it's important to bring up a very important part, which is these aren't stem cells. And I think that's one of the major problems is that there is no stem cell therapy anywhere. Unless when you go to Mexico and get stem cell therapy, what are you actually getting? I don't know, but they're not stem cells. I mean, the only stem cell, I mean, I can only speak what's happening in the United States, but the only stem cell therapies approved in the United States are for leukemia, blood disorders, blood diseases. There is no stem cell. In fact, the FDA has a big warning page with a video that explains there are no stem cells. Stem cells implies that I'm going to inject cells into you and those cells are pluripotent. They have the ability to become something else and those cells are now going to become your cartilage. They're now going to become your tendon. That doesn't happen. In fact, right now, what seems to be happening? What's the identity of the stem cell? In other words, what is the signature that allows that doctor to know or at least believe they have a stem cell? Because these are not a tolligus, typically at these clinics, right? Aren't they... You know, someone else is... I only say that because everybody I know is basically going abroad, although I know some people that have done this here. They tear the rotator cuff and they go and get stem cells injected and six months later, the rotator cuff is fine without surgery. Sort of that type of thing. And it goes. Yeah. That first of all, it's illegal to actually give stem cells. So a few years ago, people were able to get products that were manufactured by companies who were selling umbilical cord blood or some derivative of umbilical cord, some umbilical product as stem cells. Wartons jelly, it's some of it's called exosomes. All these things are not allowed. The FDA will not let you inject this into anybody. And what's the reason for that? So the FDA has a division that will... That regulates the use of human cells, tissues and products. Even if a tolligus, even if you're even if they're your own. You can use your own as long as it's not manipulated or what we considered minimally manipulated. So spinning is not a manipulation? Spinning, that's right. So you can take your bone marrow out of the pelvis and we get it from the pelvis and you can concentrate that. But you can't give any enzymes to it, you can't digest it, you can't make any changes to that product. You can only give it as is. Now with fat, because fat has actually shown some promise with osteoarthritis of the ankle, very good studies on ankle osteoarthritis and fat injection, same with knee. You can do that because you're not... You're minimally manipulating the fat. You are taking it and making it into smaller fat particles, but you are not essentially altering the fat itself. And those... I mean, you're basically breaking down adipose tissue into individual fat cells? It's micronized, it's called micronized. It's micronized fat. And the idea is that micronized fat regrows as cartilage? No, it still doesn't. What does it grow as? So that's what we don't know. So right now, our best understanding of biologics in reality is that it reduces symptoms. It is symptom modifying treatment. And it's a good symptom modifying treatment when it works because we don't have a lot for, let's say, arthritis tendon problems. Our toolbox of things to use when someone comes in with knee arthritis or hip arthritis are pretty pathetic. It's... You're going to go to PT because that's mentioned on the help. I'll give you a brace maybe that might help. Maybe take some Cox-2 inhibitor anti-inflammatories and some cream, right? We don't have... The repertoire of what I prescribe is pretty pathetic. The non-surgical treatment for these things is pretty... So here's an opportunity with the ortho-biologic field to reduce symptoms in a safer way than, let's say, cortisone. Because cortisone is quite effective and safe as long as you're not injecting over and over again. So there's a space for this that is very reasonable. And the randomized control trials show that it works for knee arthritis probably better than anything. But the bigger... I think if we're looking forward as to what this... Yeah, what we're going to do... I know we have bigger... Why don't we have RCTs that can answer these questions definitively? Because there are a few things that I discuss with people in medicine that create more... sort of polarization around treatment than the use of these biologic therapies where the people who have had these procedures will swear up and down by them when they work, which is you don't understand. I couldn't move my arm and in six months I was fine. Of course we don't... We always fail to have the counterfactual here, which is possible your arm was just going to get better on its own. Correct. It's possible that the initial MRI showed something, but the follow-up MRI didn't show something. We're just healed on its own because it was going on its own. So the only way you can ever escape that is with randomized control trials. Are they being done? Yes. And so to that point, if we inject saline into somebody's joint, a number of those patients are going to get better. So that's sort of the standard we use. How does PRP work in comparison to saline? And there are a lot of studies. There are dozens of studies randomized controlled trials looking at PRP. And many of them have excellent results. The problem. And that's, for example, tennis elbow... For knee arthritis. For knee arthritis. That's probably of all the data, that's the tier one best data. But we know so little about this because it doesn't seem to work well in hip arthritis. And why do you think that would be? Is it just possible that the studies haven't been done correctly? Maybe. And I think this brings up a very important point. When you do a randomized control trial, let's say for a medicine of hypotensive medication, you know what dose you're giving. And you're comparing it to some other treatment where you know the dose. Plate lit, platelet rich plasma. I'm taking your platelets of unknown concentration. I'm unknown quality. Of unknown quality. I'm spinning it in a machine, either once or twice, and a different machines concentrate those platelets differently. And so then I end up with a product, with a certain amount of platelets. And then I inject it back into you. I don't even know your disease process specifically. So when you put people into a large number, into these studies, you get a lot of crappy data. So what the future holds is, and there's a push in our industry, and there's a particular association called the Biologic Association, which is like an association of associations internationally, where they've formed something called the BARB, which is a Biologic Association registry, and bio, it's a bio registry. It's a registry and a bio registry. That is, they have lots of centers, and they want to know everything about what you're injecting. They want to know what's the concentration of the blood of the patient. And what percentage of docs who are regularly giving this therapy are participating in the registry to the point where we can generate information? Very, compared to the total amount, very few, but it's enough people that we can get really good data to find out what's the aplicot, what's the dose, what's the critical dose of platelets that we need to affect change? What is, and other things, we can look at that, we can do a proteomic analysis of the actual fluid itself, and you match that with outcomes data from the registry. So you have a bio repository and a registry combined. Who did well and what did they get? And they save samples of that stuff too. But at best, this can only inform what an RCT should do. Those data by themselves don't tell us anything, right? Correct, but this gives information about to actually lead to the trial, right? So you say, okay, it looks like this works. Let's try this particular dose. So right now, PRP looks more effective at reducing symptoms than cortisone in the knee for arthritis. Is there any reason to believe it can delay the requirement for a total knee replacement? So maybe we know that if we look over the course of a year, because this is what those trials looked at, cortisone works very well in a short time frame. It's pretty impressive. The first couple of weeks you get one and it helps. There are some people who the pain comes right back. So it doesn't have staying power. When you compare steroids to PRP, the PRP, if you look out of over a year, they're doing better. Haleuronic acid, which is another thing we inject. Also is doing better than cortisone if you look out. If you combine, isn't Haleuronic acid considered biologic? It's not. Because it's an FDA approved product. It's yes, and I don't even know that it's a drug. I think it's even classified differently like a device, but I'm not 100% clear on that. So there's a number of studies, or I don't know about a number of study, I know of a very well done study that looked at Haleuronic acid and PRP together, and that seemed to be more effective, not astronomically more effective, but more effective than the treatments that we have. It's more effective, the combination of those two. But is it disease modifying? And that's the big maybe, because that's your question. And there are studies that show it may be pushing off knee replacements for those patients. But I think this is where we still don't really know yet, but there's so much deceitful behavior out there. With regards to stem cell therapy, that the organization's involved and the N, the FDA and the Federal Trade Commission, NCMS are all trying to crack down on the problem of people advertising, come onto my clinic, I have stem cells, I will inject it, it's 100% guaranteed to help you, I'm gonna give you new cartilage. And one of my colleagues at NYU did a study where they looked at a thousand websites, and 94% of those websites who were promoting stem cell therapy were making inaccurate statements. And it just, in gender's distrust between doctor and patient, when you're going for a treatment and you think they're telling you something that, I had a friend, I really, this is about two weeks ago, my close friend from high school sent me a brochure because he wanted to get an injection from his doctor of something like an umbilical cord or Wharton's Jelly injection, which is not allowed. And I look at the brochure, I said, send it to me. And I made the bigger and I circled it, and I'm the brochure, because it's from the company, the company sells it to the doctor, the doctor gives it the patient. On the brochure, it said, this is not intended to treat any condition. I was like, when I just circled it, I send it back to him. Never mind. | ↗ |