Stem cells are going to play a very important part in the future of medicine. Stem cells have been utilized for cancer problems such as leukemia, since approximately the 1960’s. In the last decade research has been devoted and is now showing success with the use of stem cells for musculoskeletal problems such as osteoarthritis, cartilage defects, tendon tears and new research is being done for degenerative disc problems of the spine. Pain Care Boise is now excited to be offering Stem Cell treatments for problems such as osteoarthritis, cartilage defects and tendon defects.

There are several sources or ways to obtain stem cells.
#1. A human embryo contains pluripotent stem cells. This means they can differentiate into any cell line( i.e. cartilage, tendon, muscle, bone, etc). Of course utilizing cells from embryos continues to be a very controversial and of course ethical issue preventing the wide use of stem cells from embryos.

#2. An induced stem cell is also pluripotent. This is a method in which you can take almost any cell (such as a skin cell) and by injecting genes or molecules into the cells one can convert the cells into stem cells. Unfortunately a concern with these cells is introducing an oncogene, which could result in cancer.

#3. Adult stem cells are what are typically used for musculoskeletal pain problems. Adult stem cells are considered multipotent which means they can differentiate into some but not all cell types. Adult stem cells may be obtained from almost every human tissue with bone marrow, adipose(fat) tissue, blood, placental blood, and placental tissue probably being the most studied. Once again there are obvious ethical reasons for not using stem cells from the placenta. With blood although we can get stem cells, they will more likely convert into blood cells rather than musculoskeletal type cells. These cells are called hematopoietic stem cells.

Adipose (fat) cells do provide a significant number of stem cells and even more than from bone marrow.
However, there are several reasons that adipose (or fat tissue) is not used as often as bone marrow. One reason is adipose stem cells do not convert as easily as bone marrow stem cells. This in part may be due to a better immunomodulatory effect within bone marrow stem cells. A second reason is with bone marrow aspirates we also get the benefit of platelets, which are typically collected along with the bone marrow stem cells. Another reason is that the FDA has decided that one of the processes, which utilizes an ‘enzyme’, collagenase, to separate the stem cells from the stroma of the adipose or fat cells is considered to be a “significant manipulation”. The FDA has decided if any cells are more than “minimally manipulated” they cannot be utilized. The FDA has approved some devices that will ‘mechanically’ process adipose. However, they continue to deter the use of adipose stating that any processing that “alters the original relevant characteristics of adipose…” is more than minimal manipulation. This ruling is presently being fought by several medical organizations.

This leaves us with the adult stem cells from bone marrow, which are the most commonly used for musculoskeletal pain problems. The bone marrow adult stem cells are often times called mesenchymal stem cells or MSCs. (As opposed to hematopoietic stem cells, which are responsible for the formation of blood cells.) MSCs are capable of differentiating into chondrocytes, which can become cartilage; or into tenocytes, which can become tendons; or into osteocytes, which can become bone; or into myoblasts, which can become muscle. What the MSCs become is highly dependent upon what cell it is living next to or what cell it is placed next to.

MSCs are not only multipotent progenitor cells (meaning they can convert into other cells), but are also referred to as immunoprivileged cells. What this means is that they are immunosuppressive and the body will not reject these cells when injected into another area of the body. They may also reduce inflammation by decreasing the activity of T cells (which contribute to inflammation).

They have a trophic property, which means they allow growth. They secrete cytokines, chemokines and growth factors. This leads us to the one concern with using stem cells. The concern is that injecting stem cells could cause tumors or cancer. This is presently only speculative. Several animal and human studies have revealed a high degree of safety with no indication of tumor growth ever reported.

MSCs also will initiate angiogenesis, which is the development of new blood vessels into the injured area. Obviously this is important to bring in oxygen and the proper nutrients as well as the ability to get rid of the waste products.

In summary, the FDA has defined two categories of human cell products:

#1. Minimally manipulated– Spinning the cells down in a special centrifuge to concentrate the cells is presently considered OK.

#2. More than minimally manipulated– a. The cells cannot be extracted and grown in a cell culture outside of the body.
— b. As mentioned above the process utilizing an enzyme to remove the stem cells from the stroma of adipose or fat tissue is presently considered more than minimally manipulated.

Based on the above information Pain Care Boise is now offering stem cell treatments by aspirating bone marrow from the iliac crest area. This is a simple procedure that can be done with image guidance. The procedure is well tolerated and takes minimal time typically under five minutes.

PRP (Platelet-Rich Plasma) maybe synergistic to the Stem Cell injections. PRP has more growth factors to release, which will aid in cell proliferation. One of the growth factors is vascular endothelial growth factor, which will further aid in the angiogenesis or formation of new blood vessels.

Although the above discussed a significant amount of science, obtaining your own readily available multipotent stem cells is easily done in a timely manner with image guidance. Your cells are then very precisely placed with ultrasound guidance into the damaged joint, cartilage or tendon by our provider, who is also certified in musculoskeletal ultrasound.

Common indications for Stem Cells:

> Osteoarthritic joints
> Cartilage defects
> Meniscus tears
> Tendon tears complete
> Rotator cuff tears complete
> Anterior cruciate ligament tears
> Achilles tendon tears
> Patellar tendon tears
> Hamstring tendon tears
> Many other tendon or ligament injuries