Knee Arthritis Treatment Options
CLINICAL
A discussion about Stem Cell Therapy, Shockwave Therapy and Laser for Knee Osteoarthritis
Part 2
Jeffrey Tueker
DC, DACRB
Most of the patients with knee osteoarthritis (OA) already know they have it when they present to my office. Most have tried some pharmacological treatment (pills, cortisone injections, creams, etc.), some have tried physical therapy, but these strategies were not fully effective. These patients still want to try something to decrease the pain but are not looking for surgery. I can remember when cortisone injections were the only medical option for knee OA. Then there was a time when Hyaluronic Acid injections were a trend. Then ‘viscous’ injection solutions were ‘in’ and some patients really benefited from all of these. Then Prolotherapy was popular and soon after Platelet Rich Plasma (PRP) therapy became ‘the thing’ to treat knee osteoarthritis. Both of these injections are still very popular and research suggests that PRP injections improved pain three months after the final treatment and is more effective in lower osteoarthritis grades than Hyaluronic Acid. (1'5)
So here I am the progressive chiropractor. The patient comes in and say’s my doctor told me I have “bone-onbone” in my knee. The patient is thinking chiropractic is the last resort before joint replacement or “Til just live with it”. Step one is making sure you look at the x-ray or MRI yourself. Our eye is different because we are used to starting with a damaged joint(s) and we have a sense of the body’s ability to self-regulate and heal. With or without imaging I do my functional exam and figure out a plan that could benefit my patient. My non-operative plan includes education, hands on therapy (manipulation, mobilization, soft-tissue therapy), joint de-loading exercises with gentle movements, weight loss if needed, bracing and taping thoughts, and a possible trial of all the modalities I have available. These interventions alone are often enough to signal the start of remodeling and healing and we see improvement happen.
Sometimes patients ask me questions about bone marrow and fat stem cell injections for joint pain. I look to the research which does support stem cell therapy. (1) Stem cell injection therapies have the ability to provide pain relief, along with the potential to regenerate lost cartilage, slow down cartilage degeneration, and improve patient mobility.(1,2) In an article by Burke et al, they refer to bone marrow-derived stem cells as having a higher chondrogenic capability (the ability to make cartilage) than fat derived stem cells.(1)
As a modern progressive chiropractor interested in evidence based information and my own clinical experience I explain to my patient that “I use laser and shockwave as regenerative orthopedic therapy to treat osteoarthritis. Each one of these therapies is supported for joint pain, so in my office I use combinations of manipulations, modalities and exercise for osteoarthritic joint pain. Sometimes I’ll refer out for stem cell therapy.” In this regard, some patients are choosing to use injections, shockwave and laser combinations. Using these combinations is all still very new but I find laser and shockwave help decrease painful knees even without the invasive and expensive procedures of stem cell therapy. Laser and shockwave therapies along with corrective exercises mentioned in article # 1 are regenerative orthopedic therapies that enable some patients to achieve repair and restore the damaged articular cartilage without the risk of injections.
"Using these combinations is all still very new but I find laser and shockwave help decrease painful knees even without the invasive and expensive procedures of stem cell therapy."
Zhang et al (3) found that bone marrow stem cells increase the cell proliferation of chondrocytes (cartilage builders) and inhibit inflammatory activity in osteoarthritis. They are saying stem cell injections regrow cartilage and I am suggesting shockwave therapy may regrow cartilage too (45). They are saying stem cell injections halt damaging chronic inflammation and I am suggesting laser therapy may stop damaging inflammation. Here’s my take on this, by getting cells in the damaged joint to talk, the hope is that stem cells will communicate with the surrounding tissue to navigate to the site of the damage and differentiate themselves into the material to build bone or other repair substance.(½8) Stem cell activation has shown results in relieving pain and reducing inflammation in patients with more advanced osteoarthritis, helping many halt the progression of the disease and the need for joint replacement.(9)
I have patient experience with four shockwave machines over the last 5 years. The brands are made by Zimmer, PiezoWave, Storz and Miracle Wave. I have used laser for 10 years and currently have two laser machines, a class 4 laser device and a class 3B laser device. I encourage doctors to try each unit and track for yourself the results you get with your patient population. Some patients with knee osteoarthritis do well with laser alone, some do well with shockwave therapy alone. For some patients I found they need every modality, every manipulation, every exercise and every joint supplement I can get them to take at the end of the day. Most of the knee patients treated with hands-on therapy, exercise, shockwave and laser are better than before treatment.
The shockwave research is as impressive as the stem cell research in that it is not limited to cartilage regrowth. Animal studies have demonstrated shockwave at the site of a bone fracture promoted rapid and accelerated bone healing. (5-7) This non-invasive therapy has helped patients achieve progressive improvement of knee pain, function and stiffness score.
We are caught in a time where I feel a shift, in that patient’s attitudes almost expect new bone and cartilage repair without surgery. However, if chronic pain goes on too long, and stem cells and or modalities have failed they expect to have joint replacement surgery to solve the issue. My personal experience with patients having stem cell therapy is accumulating but I can’t say that everyone is improving from these injections. There are studies that are following up patients after stem cell treatments (after six months), and patients displayed an increase in cartilage thickness, extension of the repair tissue over the subchondral bone and a considerable decrease in the size of edematous subchondral damage. (11-14) In my mind, this sounds like the things we have experienced with manipulation and the research is starting to support this.
In summary, if all of these therapies (cortisone, PRP, stem cell, laser, shockwave) are considered anti-inflammatory and effective for arthritic knee pain, it’s easy for me to conclude and recommend to my patient that my non-invasive therapy is safe, less costly, significant, and worth a trial of treatment before more invasive and more costly procedures.
Jeffrey Tucker, DC, DACRB, is the president of the AC A Rehab Council. He is certified through NASM andFMS. His website is www.DrJeffreyTucker.com. For information about the 20th anniversary of the 2019 AC A Rehab Symposium please visit www. CCPTR.org
References:
1. Meheux CJ, McCulloch PC, Lintner DM, Varner KE, Harris ID. Efficacy of Intr a-articular Platelet-Rich Plasma Injections in Knee Osteoarthritis: A Systematic Review. Arthroscopy. 2016 Mar;32(3):495-505.
2. Marmotti A, et al. PRP and Articular Cartilage: A Clinical Update. Biomed Res Int. 2015;2015:542502. Epub 2015 May 5.
3. Dai WL, Zhou AG, Zhang H, Zhang J. Efficacy of Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis: A Meta-analysis of Randomized Controlled Trials. Arthroscopy. 2016 Dec 22. pii: S0749-8063(16)30780-0. doi: ,1016/j.arthro.2016.09.024.
4. Forogh B, Mianehsaz E, Shoaee S, Ahadi T, Raissi GR, Sajadi S.Effect of single injection of platelet-rich plasma in comparison with corticosteroid on knee osteoarthritis: a double-blind randomized clinical trial. J Sports Med Phys Fitness. 2016 JulAug;56(7-8):901-8. Epub2015 Jul 14. PubMedPMID: 26173792.
5. Rabago D, van Leuven L, Benes L. Qualitative Assessment of Patients Receiving Prolotherapy for Knee Osteoarthritis in a Multimethod Study. JAltem Complement Med. 2016Dec;22(12):983989. Epub 2016 Sep 7.
6. Zhang Q, Chen Y, Wang Q, Fang C, Sun Y, Yuan T, Wang Y, Bao R, Zhao N. Effect of bone marrow-derived stem cells on chondrocytes from patients with osteoarthritis. Mol Med Rep. 2016 Feb;13(2):1795-800. doi: 10.3892/mmr.2015.4720. Epub 2015 Dec 28.
7. Zhao Z, Ji H, Jing R, Liu C, Wang M, Zhai L, et al. Extracorporeal shock-wave therapy reduces progression of knee osteoarthritis in rabbits by reducing nitric oxide level and chondrocyte apoptosis. Arch Orthop Trauma Surg.2012; 132:1547—15 53. doi: 10.1007/ s00402-012-1586-PMID:22825641
8. Gollwitzer H, Gloeck T, Roessner M, Langer R, Horn C, Gerdesmeyer L, et al. Radial extracorporeal shock wave therapy (rESWT) induces new bone formation in vivo: results of an animal study in rabbits. Ultrasound Med Biol. 2013; 39:126-133. doi: 10.1016/ j.ultras med bio.2012.08.026PMID:23122639
9. Huang S, Xu L, Zhang Y, Sun Y, Li G. Systemic and local administration of allogeneic bone marrow derived mesenchymal stem cells promotes fracture healing in rats. Cell Transplant. 2015 Feb 2.
10. Meheux CJ, McCulloch PC, Lintner DM, Varner KE, Harris JD. Efficacy of Intr a-articular Platelet-Rich Plasma Injections in Knee Osteoarthritis: A Systematic Review. Arthroscopy. 2016 Mar;32(3):495-505.
11. Marmotti A, et al. PRP and Articular Cartilage: A Clinical Update. Biomed Res Int. 2015;2015:542502. Epub 2015 May 5.
12. Dai WL, Zhou AG, Zhang H, Zhang J. Efficacy of Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis: A Meta-analysis of Randomized Controlled Trials. Arthroscopy. 2016 Dec 22. pii: S0749-8063(16)30780-0. doi: 1016/j.arthro.2016.09.024. [Epub ahead of print]
13. Forogh B, Mianehsaz E, Shoaee S, Ahadi T, Raissi GR, Sajadi S. Effect of single injection of platelet-rich plasma in comparison with corticosteroid on knee osteoarthritis: a double-blind randomized clinical trial. J Sports Med Phys Fitness. 2016 JulAug;56(7-8):901-8. Epub2015 Jul 14. PubMedPMID: 26173792.
14. Rabago D, van Leuven L, Benes L. Qualitative Assessment of Patients Receiving Prolotherapy for Knee Osteoarthritis in a Multimethod Study. J Altern Complement Med. 2016 Dec;22(12):983989. Epub 2016 Sep 7.
