Interview with Regenerative Medicine Leaders: Part 1

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Mouse_embryonic_stem_cells

 

 

 

 

 

 

 

Regenerative Medicine

 

Regenerative Medicine is an exciting, expanding field of medicine.  Stem cell technology is quickly expanding in the area of musculoskeletal conditions.  As physiatrists, we routinely treat musculoskeletal injuries and are therefore, perfectly aligned to be leaders in this new realm of medicine.

 

In this edition, we meet Dr. Malanga who is involved in stem cell research and clinical application, as well as active in the education of other Rehab Physicians through the AAPMR’s Regenerative Medicine course.

 

This is an excerpt from the full length article in the AAPMR CORE newsletter, for which I am editor.  In this section, Dr Malanga discusses the research and efficacy behind platelet rich plasma and stem cell technology.


Dr. Malanga

 

 

 

 

 

 

 

Gerard A. Malanga, MD

Founder and Partner; New Jersey Sports Medicine and New Jersey Regenerative Institute Cedar Knolls, NJ

Clinical Professor, PMR, Rutgers University- New Jersey Medical School

Chair, AAPM&R Regenerative Medicine Task Force   .

 

“I believe that PRP (platelet rich plasma) is effective for treating many musculoskeletal conditions.  I have personally been able to publish review articles on the topic and feel that the literature is supportive of PRP.  Also, I was fortunate to be part of a multi-center study, along with Dr. Kenneth Mautner of Emory University, looking at PRP in the treatment of tendinopathy1.   Several factors affect the efficacy of PRP: the absence of red blood cells, the concentration of PRP relative to serum concentrations, and the presence/absence of leukocytes.

 

Other than tendinopathies, the other area that many clinicians have found difficult to manage is a diagnosis of degenerative arthritis, such as in the knee, particularly in those under the age of 60.  This is an ever increasing common problem with very few treatment options.  Many patients have tried and failed a variety of nonoperative treatment measures that include: medications, strengthening and physical therapy, various injections and yet remain limited by pain.  Many are offered a total knee arthroplasty, a procedure that often requires a reduction of activity level after surgery.  It is this population, I believe, that may be better treated with mesenchymal stem cell therapies.

 

Several years ago, I researched and developed expertise in the use of bone marrow stem cell therapies in the treatment of various cartilage and osteoarthritic conditions as well as for meniscal tears.  This involved a great deal of review of various journal articles in journals that I had never before read.  I have been fortunate to learn from and exchange experiences with many other physicians around the country who are pioneers in this area.

 

Thus far, the results from stem cell therapies are promising and each year the techniques and experiences continue to improve.  There continues to be a great deal of more work to be done in this area to solidify the scientific evidence for these Orthbiologic treatments and I am excited to be working with physicians across the country who share interest in this area of medicine.”

 

 Dr Malanga is leading an upcoming review of the literature for both techniques in the medical journal PMR; and is leading the task force on Regenerative Medicine for the medical society, American Academy of Physical Medicine & Rehabilitation.  Dr Malanga has been a leader for years in the field of musculoskeletal care and I feel quite fortunate to learn from him over the years and I look forward to learning more about this very exciting therapy.

 

Good Luck!

References:

  1. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: a multicenter, retrospective review.

http://www.pmrjournal.org/article/S1934-1482(13)00003-8/pdf

 

 

Your back hurts… because of your ankle!

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No, I am not disregarding the earlier post about toilets. Let me explain. After my freshman year in college, I worked as a housepainter for two weeks. That career choice came to a screeching halt after I fell off a roof and shattered multiple bones including my left ankle. I now have a very stiff, arthritic ankle. It doesn’t even dorsiflex to neutral. In my twenties, I began having back pain and didn’t know why. I was sedentary but thin and very busy with my medical training.  I eventually realized that I had a lumbar disc herniation with occasional right leg pain. Why?

Disc herniations  happen when you have excessive flexion or twisting through a disc.  We bend over more than a thousand times a day which requires squatting.  Squatting requires full hip flexion, knee flexion, and ankle dorsiflexion.  The picture below shows a natural full squat with a lot of ankle dorsiflexion.

lady squattingNotice her degree of ankle dorsiflexion. Also, note how upright her lumbar spine is.  Her upper body is leaning on her thighs thus taking the stress off the lumbar spine which is in essence “hanging” from  her thoracic spine and not taking any significant torque.

Below is an example of a Western squat, in which the person comes up on their toes in order to get down.

Note her degree of ankle dorsiflexion.  Also, note how perpendicular her spine is to being upright.  This creates more torque on the lumbar discs than the upright posture and thus more stress on the discs.

I believe taking the weight off the heels leads to increased calf muscle activity, which leads to hamstring overactivity and inhibition of the hip muscles (ie- gluts), which lead to overactivity of lumbar paraspinal muscles and increased stress on lumbar spine.  This aligns with the work of the great Neurologist, Dr Janda.

 

 

In the above picture on the left, lack of ankle flexibility prevents her from squatting further.  If she squats further with same angle in her ankle, then she will have to lean back and thus lose her balance (also, her lumbar spine is now more parallel to the ground and thus more stressed).  In the picture on the right, having a lift under her heels allows her to keep her center of balance forward (and her lumbar spine more upright) and do a deeper squat.  This is a happier lumbar spine!

In short, healthy backs require full range of motion and strength of the whole chain.  From the lumbar spine, pelvis, hips, knees, ankles and feet.  When you have back pain, the whole system must be assessed.  The back pain is often a result of a problem elsewhere in the chain.

Good Luck!

Valley Sports & Spine Clinic
Giving you Back your Life
Dr. Ethan Colliver

 

RFA of the Knee | Valley Sports & Spine Clinic

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Do you suffer from knee pain?  You are not alone.  Knee pain is one of the most common pain complaints in the U.S., and the number one reason for joint replacement surgery. Common treatments include exercise, pain medicines (Tylenol and Ibuprofen), and injections (steroids or Synvisc/Euflexxa).

If you continue to have knee pain, knee replacement surgery is an option you could discuss with an orthopedic surgeon.  However, some patients are not ideal candidates for surgery either because they are too young (less than 60), too ill for surgery, or choose not to have surgery.

Now there is another option for persistent knee pain, radiofrequency ablation (RFA).  The knee joint is supplied by six nerves (genicular nerves).  If you disrupt the nerves, you can block the pain signals from the knee.  The RFA procedure is done in two steps.  The first step involves temporarily blocking the nerves in order to see if most of your knee pain goes away.  If so, then you can proceed to the second step––radiofrequency lesioning (disrupting) the nerves that supply the knee.  This lasts for 6 or more months and can be repeated if needed.

RFA of the knee does not affect the strength or range of motion and the patient may still have a knee replacement surgery in the future.  To learn more about this exciting new option for knee pain, check out this article from the Journal of Pain, May 2011, by Choi, WJ:
Radiofrequency treatment relieves chronic knee osteoarthritis pain: a double-blind randomized controlled trial.

Valley Sports & Spine Clinic
Giving you Back your Life
Dr. Ethan Colliver