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Osteoarthritis:  Joint pain
From Diagnosis to Treatment

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Osteoarthritis is perhaps one of the most common reasons for joint pain. It can affect both weight-bearing and not weight-bearing joints.  Weight-bearing joints include your hip joint or knee and ankle.  Other joints that there are non-weight bearing also can be affected by osteoarthritis.  It is considered a degenerative condition and aging is a big factor.  Other factors that can accelerate the process include excessive weight, work injuries, fractures, and previous meniscal and ligamentous injuries.

Joints are supported by tendons and ligaments.  Sometimes the pain is not coming from the joint itself but it is coming from supporting tendons, ligaments, and bursa.  Your doctor should be able to differentiate between joint-related pain and soft tissue that surround the joint.


Symptoms:
Swelling, pain, stiffness in the morning, pain with weight bearing including walking and standing for lower extremities, and movement of the arm for the upper extremity joints are common presentations. If osteoarthritis is involving your spine, the motion of the spine can be painful. In small joints of hands and feet, moving the toes and fingers, gripping something with the hands, and making a fist can be painful in those particular joints.


Work-up:
X-rays are often sufficient for the diagnosis of osteoarthritis.  Sometimes to differentiate joint pain from other causes of pain within the joint, an MRI may be indicated.  For soft tissue pain around the joints including issues with the tendon and bursa, ultrasound can be helpful.

 

Treatment:

Your doctor may recommend a variety of treatments to you.  Most of the time, conservative care is recommended.  Conservative care includes physical therapy for strengthening the muscles around the joint, improvement of range of motion, reducing inflammation of the joint, and overall improvement of function.  The physical therapist will work with you to improve the utility of the joint.

If the physical therapy is not effective, you may combine this with medication which includes

 

In terms of medications Tylenol, and some of the NSAIDs can help the pain. Risk assessment is to be done between physicians and patients regarding the potential side effects of any medication you take. Opioid medications are generally not recommended, although if you have joint replacement surgery, for the first 10 days, you may be prescribed such medications.

Steroid Injections:
Injections into the joints can be effective to relieve pain most common injection is a steroid injection into the target joint.  X-ray or ultrasound should be used to direct the needle within the joint space.  If effective, this could be repeated from time to time although frequent injections of steroids or anesthetic can deteriorate the structure of the joint. In some cases, viscosupplementation can be recommended.  This is most commonly done in the knee joint but has been tried for other joints as well.

Surgeries:

For end-stage joint disease, surgery is recommended.  Often this would be a joint replacement surgery.  Not every joint can be replaced but many joints can be and orthopedic surgeons are skilled to do so.  Recovery can be 2 to 6 months depending on the joint replaced.  Outcomes are generally good.

Regenerative Treatment  for Osteoarthritis  (PRP or B-MAC) 

The most recent musculoskeletal trend is to pursue regenerative treatments.  Often PRP and bone marrow aspirate are considered.  Some patients undergo prolotherapy.  The goal of regenerative treatments is to spare patients from steroids, reduced inflammation of the joint, improve flexibility, and ultimately, regenerate tissues that they have degenerated. There are lots of research to be done on these but over the past few years, these options have shown some promise.  Insurance does not cover these treatments. Read More 

Examples of arthritic joints that we treat include:

1.  Hip osteoarthritis (Hip Injection

2.  Knee osteoarthritis (tibiofibular joint, patellofemoral)

3   Ankle osteoarthritis

4.  Shoulder osteoarthritis (AC joint or glenohumeral) 

5   Elbow osteoarthritis

6   Wrist osteoarthritis

7   Fingers and toes osteoarthritis

8.  Spine Osteoarthritis

Regenerative Medicine

In the past few years, as regenerative medicine treatments have advanced, alternative treatments including PRP (Plasma Rich Platelet) and stem cell treatments have become available to patients for the management of painful joints due to osteoarthritis or soft tissue injuries of the joint.

PRP injection for Osteoarthritis:
PRP treatment has received significant attention from the media and has been used by numerous professional athletes, including NFL and NBA players to accelerate healing. These athletes are trying to avoid frequent steroid injections and they are more interested in repairing the injured and overworked tissue rather than temporarily decreasing inflammation with cortisone injections.  The use of PRP is not limited to professional athletes.  Nowadays, it is offered to any patient with appropriate diagnoses for which PRP can help. 

 

PRP or concentrated blood primarily consists of your platelets. Plasma is a fluid component of the blood.  Platelets are one of the components of the blood.  We are able to separate the platelets from the rest of the blood and inject them into the target joint for improvement of pain, function, and regenerative effect.   As PRP is prepared from your own blood, the risk of reaction is low. As with any injection, there is a risk of injury to any structures in the area as well as a low risk of infection. The treatment course may require a series of 1-3 injections. However, future injections are not recommended if there is no improvement in symptoms with the initial course of treatment.

What is a PRP  injection Like?

PRP injection is relatively simple.  This starts with obtaining 30 or 60 cc of blood in a sterile fashion and transferring it to a centrifuge so the platelets and the plasma could be separated from the rest of the blood.  Once the concentrate is available for treatment, your doctor will inject it into the target tendon or joint.  Usually, an X-ray or ultrasound is used for the precise placement of the needle and delivery of the PRP into the diseased tissue. We have the PRP system that provides the highest yield of platelets as compared to any other devices in the market.  Therefore, our PRP quality is the best that could be offered to you anywhere ( Claim based on studies done on PRP machines and single splint versus double splint techniques  ).  The quality of PRP and the number of platelets delivered to you makes the most difference in the outcome of your treatment.  Not all PRP treatments /Preparations are the same!

1.  Arrive 30 minutes early. Hydrate well prior to the procedure.  
2.  Let us know if you have any bleeding disorder
3.  Do not take NSAIDs such as ibuprofen or Naprosyn for 2 weeks prior to the procedure
4.  Do not take aspirin for 2 weeks prior to the procedure
5.  You will be observed for 30 minutes after the treatment
6.  Biologic treatments take time to take effect.  You will start seeing the difference 2 to 4 months after the treatment 
7.  We may ask you to start physical therapy 6 weeks after the treatment
8.  For tendon treatment, PRP combined with shockwave therapy may have a superior effect.

How much does the treatment cost?

As of 2023, insurance does not cover PRP.  This will be a self-pay treatment.  We have a 50 %  discount for a second joint or tendon treated on the same date of service.  

Tendon or joint injections: $1100 Per joint  
Spine injections: $1700 per disc, per 2 facets, per single sacroiliac joint

No separate charge for ultrasound or X-ray use

 

We have another dedicated PRP segment on our website  Please click here to read more about Platelet-Rich Plasma for Spine & Skeletal Disorders

Stem Cell Therapy for Osteoarthritis 

Stem cell treatment for osteoarthritis is a new alternative way to help manage the symptoms of this chronic disease. As new research and treatment strategies have emerged, stem cell therapy has risen in popularity for the management of degenerative joint conditions. Results of several early clinical studies of stem cell treatment for osteoarthritis have shown promising results (see the end of this document for a list of studies). This breakthrough in regenerative medicine shines a light of hope on those battling this degenerative disease.   When the individual is treated with stem cell therapy, we take advantage of the stem cell’s ability to differentiate into chondrocytes (cartilage cells) when injected into the arthritic joint. Improvement in the health of the cartilage within the joint results in decreased inflammation, improvement of range of motion, and ultimately improvement of pain and enhanced function. If successful, it may spare a patient from the immediate need for surgical intervention.   In general, we have 2 types of stem cells. Human embryonic stem cell (pluripotent) or adult stem cell (Multipotent- Mesenchymal). Adult stem cells have been identified in many organs and tissues. These stem cells are thought to reside in a specific area of each tissue where they remain quiescent (non-dividing) for many years until they are activated by a normal need for more cells, or by disease or tissue injury. 

Autologous Stem Cell (from patient to his/herself)

This is the most common source of stem cells for the treatment of osteoarthritis in the USA. Stem cells that are used are driven from either the bone marrow (iliac crest) or adipose tissue (abdominal fat) of the individual with osteoarthritis. Both adipose-driven adult stem cells, as well as bone marrow stem cells, produce a large number of growth factors and other molecules including cytokines and chemokines. The growth factors assist with the natural course of healing and some of the cytokines and chemokines are anti-inflammatory.  A bone marrow aspirate-based stem cell goes through a centrifuge without any further manipulation and is reinjected into the patient's target joint. Any positive effect would be experienced 2 to 4 months after the treatment.

What is a  Bone marrow aspirate Therapy Procedure Like?

Bone marrow contains stem cells and other blood components.  It could be a good source for treatment of skeletal injuries, degenerative conditions which may respond to progenitor cells.   The treatment is relatively easy.  The bone marrow is aspirated from you, centrifuged, and the components are injected back into the target joint.  The aspiration of the bone marrow is considered harvesting.  There is no cell manipulation involved but there is a centrifuge process to separate the components needed for the treatment.

1.  You should hydrate well, and avoid anti-inflammatories, aspirin, and some anticoagulants as instructed.
2.  Bone marrow will be aspirated from your hip using X-ray guidance.
3.  The bone marrow aspirate will be filtered, centrifuged, and the concentrate will be available for treatment
4.  The bone marrow aspirate will be then injected into the target joint
5.  You will be observed for 30 minutes prior to discharge home.
6.  You will be seen in follow-up 2 weeks and 4 months after the procedure.  We will take time for biological processes to take effect.

 

How much does the treatment cost?

In the United States mesenchymal stem cell therapy is considered investigational for all orthopedic applications.  Until numerous double-blind randomized studies are performed, and hopes are that at some point in the near future, it will not be covered by the insurance.  For this reason, this service is an out-of-pocket expense to the patient.  In this practice, the cost of a single joint stem cell treatment is 3,800 USD.  There is a 50% discount for the second joint treated when an autologous stem cell is used. 

NIH and FDA Stance on Stem Cell Therapy

According to the United States National Institute of Health  (https://stemcells.nih.gov)  “Pluripotent stem cells offer the possibility of a renewable source of replacement cells and tissues to treat a myriad of diseases, conditions, and disabilities including Parkinson's disease, ALS, spinal cord injury, burns, heart disease, diabetes, and arthritis.”  As of November 2017, FDA has a different stance on stem cell treatment.  According to the FDA, “Stem cell products have the potential to treat many medical conditions and diseases. But for almost all stem cell products, it is not yet known whether the product has any benefit—or if the product is safe to use.  The only stem cell-based products that are FDA-approved for use in the United States consist of blood-forming stem cells (hematopoietic progenitor cells) derived from cord blood.  Bone marrow also is used for these treatments but is generally not regulated by the FDA”. ( www.fda.gov/ForConsumers/ConsumerUpdates/ucm286155.htm).  Currently, treatment of osteoarthritis with stem cell treatment is considered experimental in the United States. Stem cell therapy is in compliance with CFR21 Part 1271 (1271.15.b). Stem cell procedures are not new to the United States.Bone marrow transplants (stem cell transplants) used to treat patients with leukemia is a similar treatment; bone marrow transplants also, are not approved by the FDA but are listed as an exception as stated in CFR 1271.15.b.

 Recent Studies to review :

  • Efficacy and Safety of Intra-Articular Platelet-Rich Plasma in Osteoarthritis Knee: A Systematic Review and Meta-Analysis.(Read Here) 

  • Comparison of Functional Outcome of Single Versus Multiple Intra-articular Platelet-Rich Plasma Injection for Early Osteoarthritis Knee (Read Here)

  •  Single intra-articular injection with or without intra-osseous injections of platelet-rich plasma in the treatment of osteoarthritis knee: A single-blind, randomized clinical trial ( Read Here

  • Cytotherapy.  Intra-articular knee implantation of autologous bone marrow-derived mesenchymal stromal cells in rheumatoid arthritis patients with knee involvement: Results of a randomized, triple-blind, placebo-controlled phase 1/2 clinical trial.2018 Feb 7. pii: S1465-3249(18)30001-X. doi: 10.1016/j.jcyt.2017.12.009.

  • Regen Med.  Human adipose-derived mesenchymal stem cells for osteoarthritis: a pilot study with long-term follow-up and repeated injections   2018 Feb 8. doi: 10.2217/me-2017-0152. [Epub ahead of print] .

  • Arthrosc Tech. Adipose-Derived Stem Cell Transplant Technique for Degenerative Joint Disease.

  • Curr Opin Rheumatol. Stem cell-based therapies for osteoarthritis: Challenges and opportunities.  2017 Oct; 6(5): e1761–e1766. Published online 2017 Oct 2. doi:10.1016/j.eats. 2017.06.048 PMCID: PMC5795060. Curr Opin Rheumatol. 2013 Jan; 25(1): 119–126. doi:  10.1097/BOR.0b013e32835aa28dPMCID: PMC3616879NIHMSID: NIHMS453933.

  • Trophic Activity and Phenotype of Adipose Tissue-Derived Mesenchymal Stem Cells as a Background of Their Regenerative Potential

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