The Power to Heal Comes from Within

Powerful chemical weapons, also known as drugs, and sophisticated surgical procedures have dominated the practice of medicine for many decades.  For at least the last 15 years, maverick researchers and physicians have been exploring biologic alternatives to drugs and surgery.  Instead of searching the world for a novel chemical compound or engineering a sleek surgical device, they have looked in an unusual place--inside the body itself.  Could it be possible that the power to heal comes from within our own bodies?  The answer today is a qualified yes.  

Think about it for just a moment.  Next time your get a small paper cut, simply observe what happens.  You bleed a little.  It stops on it own.  You put a bandaid on it and magically it heals over the course of less than a week.  Similarly, if you sustain a simple fracture, it typically heals on its own with immobilization and a few weeks of time.  Your liver is your most amazing regenerative organ.  You can literally cut out a lobe of your liver and transplant it into someone else.  That missing lobe will then regrow on its own.  Skin, bone and liver are tissues that have excellent capacity to self heal. Other tissues need a helping hand.  Fortunately, within our own bodies are many tissues that can help heal other tissues.  Blood, bone marrow and adipose tissue (also known as Fat) are three examples.

To begin, let's explore platelet rich plasma, also known as "PRP".  PRP is a component of blood that can be prepared using a simple desktop sized centrifuge in about 10 minutes.  I have using PRP to treat chronic tennis elbow now for more than a decade with excellent success rates.  Multiple studies now confirm the value of PRP in the treatment of this common disorder.  A recent meta-analysis of randomized controlled trials noted PRP to be "of great clinical significance."  PRP has also been used to treat diabetic foot ulcers, knee arthritis and degenerative disc disease.  Overall, there are now more than 8600 published studies evaluating the basic science and clinically efficacy of PRP.   Importantly, in all of the areas studied, PRP has an excellent safety record.  That of course makes sense.  PRP is simply a component of your own blood.

Cancer immunotherapy is another example of using your body to help heal itself.  Cancer immunotherapy essentially reprograms your immune system to help fight nasty cancers.  Recently published data has found an "unprecedented" 94% of patients with a specific type of blood cancer achieving complete resolution of their symptoms.  The technique involves removing your own white blood cells, reprogramming them to attack tumors in the lab and then injecting them back into your body.  To quote one researcher, "This is really a revolution."

Finally, a therapy that sounds like it came out of a science fiction or horror movie is just beginning.  The idea of parabiosis involves merging the circulation of two animals.  The original research was done in young and old rats in 1956.  For the details please review a tantalizing paper entitled "Experimental Prolongation of the Life Span (Ref 1)  When their circulations were connected, the young mice started becoming "old" and the old mice started to appear "young".  Something in the blood of young mice was helping reverse the affects of aging in older mice.  The coats of the old gray mice were turning brown again.  Other research conducted at Stanford suggested young blood could boost brain cell growth in older mice.  (Ref 2, Ref 3 Ref 4)  This research was so intriguing, it led to the development of a clinical trial focused on the transfusion of young blood to older patients with Alzheimer's disease.   Silicon Valley tycoons are also helping finance similar "treatments" for middle aged rich people who want to stay young or reverse the affects of aging.  A company has even been started and is presently conducting clinical trials.  Interestingly, the company is named Ambrosia after the mythologic Greek drink that was supposed to confer longevity or even immortality.  Peter Thiel, an iconoclastic venture capitalist , appears to be quite interested in this approach to combating the aging process.  This approach is clearly not yet proven but is intriguing.

If we are seeking transformative solutions to difficult problems, I suggest we look inside.  We might just find the power to heal.

Allan Mishra

Top 7 Life Lessons from Steve Martin

A few years back I was very lucky and blessed to play poker with Steve Martin in Las Vegas with my friend Phil Hellmuth.  The three of us also had a fantastic dinner discussion that has made an enduring impression on my life. 

Mr. Martin is a superb writer, musician, actor, and producer.  He also recently hosted the Saturday Night Live 40th reunion show and expertly managed the egos of dozens of elite stars from music, TV and the movies. We can all learn from his sublime approach to work and life. 

7 Life Lessons from American icon Steve Martin

1.  “Be so good, they can’t ignore you”

2.  “It’s pain that changes our lives” 

From Shopgirl

3.  “Thankfully, persistence is a great substitute for talent”

From Born Standing Up, A Comic’s Life

4.  “I thought yesterday was the first day of the rest of my life but it turns out today is.”

5.  “I have found that-- just as in real life--imagination sometimes has to stand in for experience.”

From, An Object Of Beauty

 6.  “I just believe that the interesting time in a career is pre-success, what shaped things, how did you get to this point?”

From, Born Standing Up: A Comic's Life

7.  “Were they beautiful? We were all beautiful. We were in our twenties.”

Thank you Mr. Martin for sharing your immense talent with the world.  Please share his wisdom with your network.

AM

Ref:   http://www.goodreads.com/author/show/7103.Steve_Martin

Visit the site for more Steve Martin quotes

PowerKnee Program

DareToBeVital.com  Knee pain is a very common problem.  There are many potential remedies but one that is often ignored is diet and exercise.  This led me to develop the PowerKnee Program.  It is a simple set of exercises that may help improve the pain associated with a variety of knee problems including arthritis.  The exercises help address quadriceps strength, hamstring flexibility and overall lower extremity fitness.    This program can be found at PowerKnee.com.  Pass on the link to your friends and colleagues.

POWERKNEE PROGRAM (See Videos below)
1.  QuadCrunch (TM):  Perform a set of 3 hold for 5 seconds, 3 times per day
2.  Hamstring Stretch:   Perform a set of 3, hold for 5 seconds, 3 times per day
3.  Exercise Bike:          Ride for 30 minutes, 3 times per week, Record calories

Also, maintain or work toward your ideal body weight.  Losing even a small amount of weight may improve your knee pain and function.

Get going today on the #PowerKnee Program.  Pass on the link to your friends and colleagues.

Text "KneePain" to 22828 for a FREE newsletter to help with Knee Pain








DareToBeVital.com

DO NOT BEGIN ANY EXERCISE PROGRAM WITHOUT FIRST CHECKING WITH YOUR DOCTOR.
THIS WEBSITE IS FOR INFORMATION PURPOSES ONLY.  CONSULT WITH HEALTHCARE PROFESSIONALS TO DETERMINE IF IT IS RIGHT FOR YOU.

AM
TotalTendon

Microfracture Surgery Jadaveon Clowney

The Houston Texans' Jadeveon Clowney recently underwent "microfracture" surgery on his ailing right knee.  (See ESPN report)

The report suggests the talented Mr. Clowney will be out for 9 months or more.  Just what is microfracture surgery and why does it take as long to recovery as it does for a baby to born?

Microfracture Surgery

Let's start with the basics.  There are two types of cartilage in the knee.  The surface cartilage which covers the bone.  This is known as articular cartilage and can be thought of a type of cap or covering of the end of the bone.  This cartilage is present in any joint.  In the knee, there is another type of cartilage, the meniscus cartilage.  There are two menisci in the knee--medial (inside) and lateral (outside).  When the surface "articular" cartilage is damaged, the knee can become quite painful especially with loading and twisting.  Think rushing a passer for example.  Similar symptoms can occur when the meniscus is torn.  It is often difficult to distinguish between the two in terms of which one is the pain generator.

Microfracture surgery is an attempt to create a tire patch over a cartilage defect by poking a hole in the end of the bone and creating an access channel to the bone marrow.  The bone marrow then leaks out via the holes that are created and forms a clot which over time can help cover the defect.  It takes time, many months, for this surgery to work because the "patch" needs to mature.  This technique is useful for small defects in the cartilage but hasn't proven to be great for larger defects.  We do not know the size of Mr. Clowney's knee cartilage injury.

Recent evidence suggests that the addition of platelet-rich plasma can enhance microfracture surgery results.  This has been shown in basic science, preclinical and now clinical studies.

This type of surgery at such a young age is clearly not a good sign.  In the long run, he may require further intervention.  Please read the post below for further information about why we need to accelerate our regenerative medicine efforts.  Mr. Clowney is one of tens of millions of people worldwide with symptomatic cartilage damage.  We need to maximize outcomes of today's surgical techniques and develop new procedures to help keep our athletes and patients in the game.

AM

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Billion Second Challenge

“Billion Second Challenge” 

How would I live if I treated every second as precious? 

This is a post about time, not regenerative medicine.

A shiny crimson card was waiting in my snail mail pile when I returned from a special birthday vacation.  I actually had to Google “AARP” to confirm the acronym stood for “American Association of Retired Persons”.  Did this new piece of bloody colored plastic mean I am now “retired”?  Or, did it simply confirm I am officially old and beyond the highly desirable 18-49 demographic?

I quickly picked a number out of the air and said to myself, I’ll make it to 85 years old.  That would mean I have about 35 years left. That is 12,775 days, 306,600 hours, 18 million minutes or about 1.1 billion seconds.  It turns out the Social Security Actuarial Life Table pegs my remaining time at 29.45 more years or about 928 million seconds.  I, therefore, averaged the two numbers and came up with about one billion seconds left on the planet.

To sharpen my time focus, I have started measuring how I spend my seconds.  Each 1000 seconds equals about 17 minutes.  Each 10,000 seconds equals about 3 hours.

Simply measuring how you spend your seconds, much like calorie counting, will alter your behavior. 

How would I live if I treated every second as precious? 

Perhaps you have more or less seconds left in your life than me.  Carefully consider how you spend them.  

I call it the Billion Second Challenge. 

Post suggestions about how to best spend your next hundred, thousand, million or billion seconds and please share this post with your connections.

AM

Hamstring Injuries Treated with Platelet Rich Plasma Return to Play Faster than Rehab Alone

Hamstring muscle injuries are very common in a variety of sports including track, soccer, football and basketball.  A recently published study in the American Journal of Sports Medicine (AJSM) found athletes that were treated with platelet rich plasma (PRP) injections returned faster to their sport when compared to rehabilitation alone.  In the study, the PRP patients returned at an average of 26.7 days compared to 42.5 days in the control group (P = .02).  (reference) This greater than two week difference in time to return to play after this common injury is clinically and competitively important.

Another recently published in the New England Journal of Medicine (NEJM) found no difference between PRP injections (2 injections spaced about a week apart) and a control group.  Interestingly, both groups in this study returned to play at 42 days, very similar to the control group in the AJSM study.  (reference)

Why are these results conflicting?

One important difference between the two studies is the type of PRP used to treat the patients.  In the study that did show a difference, white blood cell enriched PRP (leukocyte enriched PRP) was used.  In the study that did not show a difference, white blood cell  poor PRP (leukocyte poor PRP) was used.  This is a clear example of why PRP formulation matters.

The data published in elite, peer reviewed journals suggests leukocyte enriched PRP helps return athletes more than two weeks faster than rehabilitation alone after an acute hamstring injury.  No difference in return to play can be expected if leukocyte poor PRP is used in this patient population.

As PRP and other cell therapies continue to evolve, it will become increasingly clear that formulations much match indication.  Patients, researchers, and clinicians need to realize not all PRP is the same.

AM
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Fat Stem Cells help Knee Arthritis

Knee Arthritis is a very difficult problem to solve.  Millions of patients suffer daily from this progressive disease state.  A variety of novel biologic therapies are in development.

Stem cells can come from a variety of sources including your own fat.  These cells are known as adipose derived stem cells.  A recent study from Korea suggests there is value using this type of cell for knee arthritis.  Researchers gave patients escalating dose of the cells and found the high dose resulted in improved pain and function scores.  They also found the cartilage defect defect size decreased while the volume of cartilage in the knee increased.

Fat Derived Stem Cells

This data is encouraging and will need to be repeated prior to broad clinical use.  (See abstract below)

For patients with this problem, the horizon is bright with many potential options like stem cells from your own fat.

AM
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Stem Cells. 2014 May;32(5):1254-66. doi: 10.1002/stem.1634.

Intra-articular injection of mesenchymal stem cells for the treatment of osteoarthritis of the knee: a proof-of-concept clinical trial.

Jo CH1, Lee YG, Shin WH, Kim H, Chai JW, Jeong EC, Kim JE, Shim H, Shin JS, Shin IS, Ra JC, Oh S, Yoon KS.

Author information

Abstract

Mesenchymal stem cells (MSCs) are known to have a potential for articular cartilage regeneration. However, most studies focused on focal cartilage defect through surgical implantation. For the treatment of generalized cartilage loss in osteoarthritis, an alternative delivery strategy would be more appropriate. The purpose of this study was to assess the safety and efficacy of intra-articular injection of autologous adipose tissue derived MSCs (AD-MSCs) for knee osteoarthritis. We enrolled 18 patients with osteoarthritis of the knee and injected AD MSCs into the knee. The phase I study consists of three dose-escalation cohorts; the low-dose (1.0 × 10(7)cells), mid-dose (5.0 × 10(7)), and high-dose (1.0 × 10(8)) group with three patients each. The phase II included nine patients receiving the high-dose. The primary outcomes were the safety and the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) at 6 months. Secondary outcomes included clinical, radiological, arthroscopic, and histological evaluations. There was no treatment-related adverse event. The WOMAC score improved at 6 months after injection in the high-dose group. The size of cartilage defect decreased while the volume of cartilage increased in the medial femoral and tibial condyles of the high-dose group. Arthroscopy showed that the size of cartilage defect decreased in the medial femoral and medial tibial condyles of the high-dose group. Histology demonstrated thick, hyaline-like cartilage regeneration. These results showed that intra-articular injection of 1.0 × 10(8) AD MSCs into the osteoarthritic knee improved function and pain of the knee joint without causing adverse events, and reduced cartilage defects by regeneration of hyaline-like articular cartilage.

Biologic Orthopedic Update from Las Vegas

The TOBI biologic orthopedic meeting this past weekend in Las Vegas was simply outstanding.  Dr. Steve Sampson put together an excellent collection of lectures and then followed by an impressive ultrasound anatomy session by Dr. Jay Smith from the Mayo Clinic.   Hands on injections and bone marrow aspiration in a cadaver lab completed the stellar conference held at the Red Rock Resort.

Las Vegas Red Rock Area

Some highlights of the sessions.  We heard about the use of PRP in soccer players from Dr. Imtiaz Ahmad from London, England, the use of PRP for osteoarthritis from Dr. Brian Cole from Chicago, the use of adipose-derived stem cells for the treatment of knee osteoarthritis from Dr. Yun Choi from South Korea, minimally invasive techniques for articular cartilage damage from Dr. Neil Ghodadra from Los Angeles and the Andrews Institute Experience using Biologics to Accelerate Healing from Dr. Adam Anz.   Lectures about hydrodissection using ultrasound (Dr. Lam, Hong Kong), the current landscape of disc regeneration challenges and promises (Dr. Bae, Los Angeles) and the value of mesenchymal stem cells (Dr. Caplan, Cleveland) were also given.  That was just part of day one of the conference.  Day two included several more interesting and important lectures.  I think there were over 300 attendees and many more following the streaming video (including myself on day one).  In between the lectures, discussions were carried out in the hallways and exhibit area.  Overall, it was a fantastic international event.

The field of biologic orthopedics is exploding.  Worldwide interest in minimally invasive techniques to treat challenging musculoskeletal problems is rising rapidly.  It will still take time, effort and some luck to discover and develop clinically meaningful treatments.  The good news is, progress is definitely being made toward these lofty goals.

AM
TotalTendon

Can Curry Cure Knee Arthritis?

It sounds like a plot for a silly Bollywood movie, but published data actually supports the idea that one of the key components of curry powder can help alleviate pain for patients with knee arthritis.

Curcumin, a bright yellow spice found in curry powder, recently was found to have the same efficacy as ibuprofen (the active ingredient in Motrin and Advil) for patients with knee arthritis.  In a recently published study of 367 knee arthritis patients, researchers found 1500 mg of Curcuma domestica extract had the same effectiveness in terms of pain reduction as 1200 mg of ibuprofen at four weeks (Kuptnirataikul et al). Importantly, the curcumin treated patients had less episodes of abdominal pain or discomfort compared to the ibuprofen patients.  Importantly, another published study of of the same dosage of curcumin (1500 mg) was found to have significant improvements in terms of pain and physical function when compared to placebo at six weeks (Panahi et al).   Curcumin has been noted to block several substances involved in the inflammatory pathway and also inhibits activation of free radicals.  This could help explain why the spice works to reduce pain in arthritis patients.  

So next time your knee starts to hurt, put down the ibuprofen and hobble over to your favorite Indian or Thai restaurant for a tasty curry meal.  It may just help your knees feel better.

On a more serious note, the published data supports trying a curcumin supplement 1500 mg per day divided in three doses for 4-6 weeks for patients with knee arthritis.  (See chart below)

AM
TotalTendon

Pain Reduction in Patients with Knee ArthritisKuptnirataikul et al

Best Overall Exercise: PowerKnee Bike Program (Knee OA Part 4)

The PowerKnee Bike Program uses an upright exercise bike to work out all of your leg muscles.  It is the best overall exercise for knee pain and arthritis because it can do so much for you without significant impact on the joint.   By simply riding the exercise bike for 30 minutes 3 times per week you can also improve your cardiovascular fitness and burn a bunch of calories.  See the video below for details.

Record the calories you can burn in 30 minutes and compare your results week by week for a month.  If you are consistent in applying the PowerKnee Bike Program you have an excellent chance of decreasing your pain and improving your knee function.

As always, check with your doc before beginning any exercise program.

AM
TotalTendon

Best Initial Knee Stretch "The Hammy" (Knee OA, Part 3)

Your hamstring tendons start on your pelvis and insert behind and below your knee. In almost every person, these tendons tighten with time.  Stretching your hamstring tendons is one of the best exercises you can do for your knee and back.  One study found "individuals with and without osteoarthritis of the knee are able to demonstrate immediate beneficial adaptations to a stretching intervention."
Reference

I recommend do a set of 3 hamstrings stretches, 3 times PER DAY.  Stretching multiple times per day is better than stretching only once a day or not at all.  You may be surprised with your improved flexibility if you are consistent about stretching.  See the video below for a simple stretch that can done anywhere.  I call it the "Hammy Stretch".



Start by placing your leg on a step, or low table.  Keep your back straight and your toes pointed toward the ceiling.  Then, simply hinge forward at your waist.  You will likely feel the stretch in the back of your thigh, knee and calf.

Consistency is the key to improvement.  Try this simple exercise and it will help your overall knee health and improve your ability to straightening your knee.  Hamstring stretching is like sunscreen, it is best to start early and continue to stretch throughout your life.

As always, check with your own doctor before beginning any exercise program.

Next time, we reveal the simple yet highly effective way to strengthen all of the muscle of your legs.

AM
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Losing Weight Helps Knee Arthritis Pain

Knee arthritis has no cure, but one treatment consistently decreases pain---Weight Loss.  It is not simple but it is effective.

What stops patients with knee arthritis from losing weight?
1.  No clear, simple program that produces weight loss and improves function.
2.  Lack of will power
3.  No consistency

Here are a few simple tips:
1.  Eat one less bite of everything. (The one-less diet)
2.  Drink less soda and alcohol
3.  Exercise

But you say, I can't exercise because my knees hurt.  I cannot count the number of times I have heard that one.  Instead of complaining.......
1.  Try stretching to start
2.  Try water aerobics
3.  Try an exercise bike (30 minutes 3x/week)

Hamstring Stretch


Set a goal of losing 3 pounds to start.  You knees may feel like you lost up to 15 pounds because of the joint forces that occur especially when you go up and down stairs.

Always check with your own doctor prior to initiating any program.

Send me any tips on weight loss and arthritis:  @bloodcure on twitter.

AM
TotalTendon


Published articles supporting weight loss for arthritis
http://www.ncbi.nlm.nih.gov/pubmed/23484617
http://www.ncbi.nlm.nih.gov/pubmed/22401872

Acupuncture with Gold for Knee Osteoarthritis

I have treated thousands of patients with knee arthritis and never heard of gold acupuncture as an option.  In the most recent issue of the New England Journal of Medicine, a case report discusses the topic.

Gold Acupuncture Knee X-ray

From the NEJM, 2013, See Link Below

Apparently, this form of treatment is common in some Asian countries.  As you can see from the x-ray above, it looks like a a bunch of pine needles or staples have invaded the knee.  I do not know of any data supporting this type of approach but it does make for a very interesting x-ray.

Here is a link to the New England Journal of Medicine Case Report:

http://www.nejm.org/doi/pdf/10.1056/NEJMicm1202540

Yoo and Yoo NEJM 2013

Please post any comments or links to data about this topic below.

AM

Platelet Rich Plasma Update, JBJS Webinar

Worldwide interest in Platelet-Rich Plasma is increasing significantly.  471 new publications have appeared on PubMed about platelet-rich plasma in just the last year, making it quite challenging to keep up with the published literature.  There has also been a dramatic rise in Google "hits" for PRP to over 1.3 million.  (See the graphs below)   New data recently accepted for publication to the American Journal of Sports Medicine confirms the value of PRP in the treatment of chronic tennis elbow.  See American College of Surgeons Report on the paper.

Tonight the Journal of Bone and Joint Surgery will be holding a webinar on the topic.  Over 1000 professionals have already signed up for the event.  This is totally unprecedented for a major, elite journal to sponsor a discussion on a single specific biologic orthopedic topic.  Follow Dr. Mishra:  @BloodCure for real time updates about tonight's webinar.

Or, consider joining the Biologic Orthopedic Society Group on LinkedIN to participate in a discussion about the webinar and other biologic orthopedic topics.

AM

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DNA Structure Discovered 60 Years Ago

One of the world's most important scientific papers was published in the journal Nature on April 25, 1953, 60 years ago today.  The entire paper was just one page!  In the short communication, James Watson and Francis Crick not only detailed the definitive structure of DNA (deoxyribonucleic acid)  but also proposed the unzipping mechanism by which the molecule could replicate itself.  They initially announced they had found "the secret of life" at the Eagle Pub in Cambridge, England.    (See the DNA diagram from the actual paper to the right)

These two brilliant men figured out the chemical structure of DNA without doing any experiments.  They started by carefully digested and then synthesizing the world's literature.  They attended conferences and sought data anywhere they could find it.  They were ridiculed for building stick models instead of conducting costly and time consuming lab investigations.  The solution to the beautiful double helix structure of DNA arose via the collaboration of biologist Watson and physicist Crick.  Neither one of them had an elite understanding of chemistry.  They even challenged and eventually proved wrong the triple helix structure proposed by famous chemist Linus Pauling.  

Sixty years later, their discovery and the subsequent research on recombinant DNA and genomic sequencing has transformed our lives.  Today, we take for granted our ability to "grow" human insulin in bioreactors and target specific cancers with molecular designer drugs.  It is appropriate to pause for just a moment today and thank the two dreamers who via their hard work and intuition discovered the structure of DNA.  Let's hope we can find and encourage many more dreamers like Watson and Crick.

AM

References:  Watson and Crick,  Nature April 1953