• Chronic Back Pain: Can Stem Cells Help?

    Back pain left me with a lot of questions as a kid. How was it possible to “throw out your back”? I thought backs attached pretty firmly to stuff in that general area. And why did this throwing out your back situation lead my parent(s) to crawl around on hands and knees for days at a time?

    As a persnickety 3rd or 4th grader, it seemed like a great way to force me to do all the cooking. Mom just pretended she couldn’t do stuff so that I would pick up the slack. A convenient method of tricking me into child labor so she could take a day or two off. I had her all figured out.

    The Back Pain Struggle Is Real

    In hindsight, I’m pretty sure my mom wasn’t super jazzed about eating nothing but overly sugared cinnamon toast and pancakes. But I couldn’t possibly have understood the crippling nature of back pain at that age. After all, I was an indestructible kid who regularly jumped out of tree forts and somehow never broke an arm. So how could sneezing bring someone to their knees?

    As a former technical trainer for a spine implant company, I now know all too well the realities of back injury and chronic pain. It affects the people I love and probably almost every person reading this – at one point or another. And honestly, we, the scientific and medical community, haven’t done a great job treating it for… oh, let’s say most of history.

    But treatments have improved recently, and you should definitely know about those improvements.

    So, let’s do a quick tour of your spine, how cool it is, what happens when it breaks, classic treatments, and cutting edge options like stem cells and nerve confounding implants.

    I know that last part sounded bad, but I assure you it’s not. It’s actually really fascinating and hope inducing. Kind of like every person who’s ever been on ancient aliens, except with a lot more hope.

    The Spine Is Important

    That’s not the understatement of the century, but it’s definitely in the top 10%. Also up there are “Kanye likes Kanye,” and “the Insane Clown Posse missed a couple of days of science class.”

    Your spine is made of 33 bones interspersed with cartilage discs. and that simple structure carries a lot of responsibility. Pun intended. #DadJokes #NotJustForDads

    Your spine has three main jobs, according to my summary of the thousand things it does:

    1. Provide structural support.
    2. Absorb shock while allowing movement.
    3. Protect nerves.

    That last one gets most of us at some point in our lives. Because we jump off of cliffs and fracture spinal bones (not referencing any person in particular that I definitely know), or throw ourselves from moving cars. And then our shock absorbing spine parts squish out onto our nerves, compressing them. Which causes pain, tingling, numbness, lightning strikes down your leg, and a whole bunch of other unpleasant symptoms.

    Spinal Injury = Pain or worse

    If we make incredibly stupid choices – like jumping off of river-spanning bridges, or if we get into a horrific car accident, the bones in our spine can become unstable. Sometimes they even get knocked out of place. Which causes some really aggressive consequences – chronic pain, loss of sensation, paralysis, loss of muscle control, and others.

    Basically, if your spine malfunctions or gets damaged, your whole body can suffer the consequences. And they are unpleasant in the extreme, ranging from mild discomfort to complete and total paralysis.

    A Lot of Back Pain Fixes Itself

    According to one study, 90% of patients with first time low back pain symptoms will get and stay better with physical therapy and time. But the more times your pain returns, the lower the probability of it improving without surgical intervention. Now, that’s *mostly encouraging*, because the data says most people get better without ever needing surgery. But if you fall into that unlucky minority, you could be stuck with chronic back pain. Unless you know your way around the treatment options. Luckily for you, I already know that stuff!

    Let’s start with the most aggressive treatment option and work our way down to the less invasive, more biologically friendly options.

    Spinal Fusion Is For Serious Back Problems

    Spinal fusion surgery typically helps patients with very serious mechanical problems in their spine. Like the instability and misalignment I mentioned earlier (and also scoliosis). So avoid jumping off of railroad bridges, tangling with the Hulk, and aggressive car accidents if you don’t want to personally learn all about this type of surgery.

    In this procedure, a surgeon removes tissue that squishes nerves, brings bones back into alignment, and places implants that give nerves enough space to breathe while also holding everything in place. At the same time, the surgeon adds graft material in the operated area so that bone will grow there and take the mechanical load off of the metal implants over time. Because, and this may shock you, metal implants don’t hold up near as well as your own bone. That’s right – titanium is no match for the incredible self-maintaining power of human bone!

    Spinal Fusion Doesn’t Always Work

    Now, at the end of this procedure, you’ll have a pretty significant recovery period ahead. And depending on which study you read, success rates range from 60% – 90%, leaving a pretty significant fraction of patients with unresolved symptoms. So after all that trouble, having your spine opened up, implants thrown in there, maybe having your personal religious leader pray over it, throwing a penny or two into a fountain, and that lengthy recovery, you could still have the same symptoms your surgery should have treated.

    Please excuse my language, but that’s pretty crappy, y’all. And it’s one of the many reasons people often just don’t want to get this kind of surgery, even if their doctor/insurance provider recommends it.

    Some mechanical problems can’t be fixed without this kind of surgery, but most people with back pain don’t have that level of mechanical issue. Meaning they likely have other options, like this next one.

    Microdiscectomy Restores Your Nerve(s)’ Personal Space

    Remember when I said earlier that the shock absorbing parts of your spine can squish into your nerve space and cause pain? When that happens, the tissue doesn’t just disappear. Especially if it registers as a large chunk of tissue. Instead, it hangs out, crowds your nerves, and generally makes a nuisance of itself. Like if your mom moved into your dorm room with you. No matter how awesome your mom is, she will cramp your college style if she shares your dorm room. And probably not in the hilarious Melissa McCarthy way either.

    Don’t worry though. Unlike the mom in your dorm room situation, a physician can easily just remove the squishy disc material that crowds your nerves. For many patients this means a return to their formerly carefree, more importantly, pain-free lives. And best of all, physicians can do this procedure through a big straw, meaning very short hospital stays, much kinder recoveries, and waaaay less risk.

    For most patients, this type of procedure leads to satisfactory pain and disability improvements, and they don’t need additional surgeries. A small portion of patients may experience recurrent symptoms at the operated level, requiring a repeat microdiscectomy or possibly a spinal fusion. But for the most part, microdiscectomy represents one of the most dependable spinal interventions we have. For appropriate patients, it works like a charm.

    Microdiscectomy In A Nutshell

    In this procedure, a surgeon simply uses surgical instruments to remove the tissue your disc has accidentally allowed to crowd your nerves. That’s the whole thing. Most patients do very well with it, but a few do end up needing further intervention.

    Bonus

    Microdiscectomy doesn’t cause irreversible changes in the same way that a spinal fusion does. With a spinal fusion, a bunch of tissue comes out, and you will never get that cartilage-squishy-shock-absorby tissue back in that spot. Which means that (after spinal fusion) microdiscectomy and the concentrated bone marrow procedure further down this post either won’t help or flat out no longer apply to the situation.

    Microdiscectomy, on the other hand, provides an option that keeps all your other treatment options open.

    Another Option: Concentrated Bone Marrow

    with mesenchymal stem cells. I mentioned this treatment in one of my first posts, because it stands as one of the few legitimate “stem cell” treatments currently available in the United States. It carries a big qualifier with it though. Injection of concentrated bone marrow only helps appropriate patients. That means patients who don’t have mechanical problems requiring spinal fusion or giant chunks of tissue suffocating their nerves. Bone marrow derived cells, stem cells or otherwise, can’t handle that kind of problem.

    What can they handle?

    Well, in this study, 26 patients whose insurance companies approved them for spinal fusion surgery had either one or two injections of their own concentrated bone marrow. That’s right – just an injection. No surgery. These patients had confirmed diagnoses of discogenic back pain, without any of the nerve compression we discussed earlier with spinal fusion. They experienced pain and disability improvements on the order of 70% at one, two, and three years post-procedure. And a couple of patients showed quantifiable improvements in the health of their discs (the squishy shock absorby part of your spine).

    Now, after three years, 6 of the patients had actually chosen to move on to spinal fusion. That probably means their pain and disability scores started climbing sometime after their initial treatment. But. That means 20 people who could have had a very invasive, irreversible surgery, didn’t. That means almost 77% of patients in the study avoided spinal fusion surgery.

    Another bonus

    Disc injection with concentrated bone marrow, just like microdiscectomy, allows you to keep your options open. If it doesn’t work out for you, you can still get literally any other treatment for your back pain.

    Note: your local doctor probably doesn’t offer this treatment. But I mentioned several who do in this post.

    Another Option: Spinal Cord Implants

    I promise it sounds a lot worse than it is, like goulash or mole. Just give me a hot minute to explain.

    Sometimes back pain does. not. respond to treatment, even after spinal fusion surgery. And that sucks. Because chronic pain can lead to depression, declining quality of life, and not having enough energy to heckle your siblings in public anymore. None of which are good things.

    Doctors, researchers, and engineers figured out a fairly elegant way to deal with this though. Instead of targeting the source of the pain, they decided to interfere with the road it takes from the source to your brain. If the pain signal can’t reach your brain, or comes through as something else (like very light tingling), then the pain disappears.

    How do they do this?

    Tiny Spaghetti Implants Block Pain Signals

    Your spinal cord basically transports information between every part of your body and your brain through electrical impulses. These spinal implants create electrical fields that change the message as it heads toward your brain. So what started as “CRIPPLING ANGRY BACK PAIN” can end up in your brain as “nothing to see here.” Since you only know the final message in your brain, these implants can literally make chronic pain disappear.

    Another cool thing about this approach: ALL pain signals get to your brain this way. So it applies to a wide variety of chronic pain conditions.

    In one study, 69% of patients receiving spinal cord stimulating implants for back pain after spinal fusion surgery reported “substantially improved or better global perceived effect,” (a measure of pain relief) at six year follow-up. And that study used old school technology. The implants available today blow that old stuff out of the water.

    You Can Try Them On – Just Like Amazon’s Clothes!

    But minus the free shipping and burgeoning shopping addiction.

    Honestly, the fact that you can try on these implants to see if they work – before actually getting a long-term implant – is revolutionary and epic. You basically visit a pain management physician, have them place the spaghetti implant in the most effective spot for your pain, then go home with a smart-phone app that lets you control the level of therapy your trial implant provides. Within a week you know whether or not it works well for you, and then you can make the decision to go ahead and have a long-term implant placed – or not.

    Yes, having a long-term implant does mean living with a small battery somewhere in your body, just like a pacemaker. But they’re so small now, and doctors are so good at implanting them that most people don’t even notice them. And if you do, you can have the whole thing removed. The whole procedure is reversible from start to finish.

    So, just as I mentioned with microdiscectomy and concentrated bone marrow injection, spinal cord stimulating implants keep your other options open. If it doesn’t work, it still doesn’t rule out most other procedures.

    For more info, WebMD has a pretty solid overview of the therapy, and this video shows you exactly where the implants go and how they work.

    Back Pain Is Terrible

    and so are super long blog posts, but look at me still writing!

    We just covered a lot of information, so I want to do a quick, brief recap. This way every reader will wonder why they didn’t just read this section first.

    1. Your spine does really important things, and it causes pain, disability, and/or paralysis when injured.
    2. Spinal fusion surgery can address big mechanical problems and relieve pressure on nerves, but it’s not exactly reversible and does shut down a lot of future treatment options.
    3. Microdiscectomy surgery removes chunks of cartilage that escape from your intervertebral disc(s) and crowd your nerves, and it keeps your future treatment options open.
    4. Intervertebral disc injection with your own concentrated bone marrow addresses discogenic pain without mechanical complications and keeps future treatment options wide open.
    5. Spinal cord stimulation implants can shut down pain signals from a wide variety of pain conditions, can be tried on like shoes or careers, and keeps future treatment options open.

    Phew, ok. I need to call it quits now. Plus it’s election day, and I have to go make sure everyone I know has voted.

    Side note: I didn’t include marijuana or opioids in this post because it’s already way too long, and they could each be their own blog category. So you’ll have to keep reading if you want to find out my opinions on cannabis (it works for some stuff) and vicodin (it’s super addictive).

    So yes, mesenchymal stem cells from your own concentrated bone marrow can help certain kinds of back pain, but we also have several other effective, patient-friendly options that don’t necessarily involve surgery.

    Alright, that’s it. Now, y’all go vote!

    Photo by Jesper Aggergaard on Unsplash

  • Why Shouldn’t I Get Steroids for My Joint Pain?

    The other night at handstands class (yes, that’s my favorite weeknight activity, and no, I am not aggressively too old for it), several of my fellow handstanders discussed the merits of getting a shot of steroids for knee pain. I think. Some sort of joint pain for sure. One person shared their experience of dramatic pain relief as a result of a similar treatment and encouraged the questioner to go ahead with it.

    Throughout this discussion I sat silently, keeping the information in this post to myself. Because no one likes a know-it-all, and nobody ever likes someone telling them not to get quick pain relief. In Texas, “shoot the messenger” is not a metaphor, and this definitely qualifies as a messenger shooting situation.

    Today I feel kind of bad about it though, but not bad enough to try to contact this person. I have just enough guilt to write this post instead of the other ones I had planned, and I think both my grandmas would agree that’s just about the perfect amount of guilt. #ThanksGrandma

    So, now that I’ve admitted to a grandma sanctioned guilt complex, let’s talk about steroids and why you should probably never get them. For joint pain.

    Steroids Treat Joint Pain

    for short periods of time.

    Doctors started using corticosteroids, to treat joint pain somewhere between the hay days of the T-Rex and the velociraptor, because they work well for a percentage of patients. But, the pain relief is fairly short-lived. In a review of 28 studies involving 1973 patients, corticosteroid joint injections relieved pain more effectively than a placebo injection for time periods of weeks, not months. In another review of 312 patients who received corticosteroids for their painful knees, pain relief lasted for a period of 3-4 weeks. The pain relief usually falls within the range of 75% at the maximum relief point and then climbs back up over time.

    So if you want pain relief for a few weeks, steroids are an ok option. As long as you read the fine print. And the fine print gets pretty hairy. In fact, the likely de-emphasized side effects of steroid injections remind me of literally every pharmaceutical advertisement I see on the gym TVs. A whispered voice or size four font appears in the last 5 milliseconds of the ad to tell you:

    “Vitallegra KP may cause sleep crime, tooth melting, fingernail reversal, circus related Tourette’s, horrifyingly realistic dreams about giant frogs, Scrabble addiction, nicotine addiction, shingles, and cheese allergies.”

    They technically told you about the side effects, but you completely miss that all important cheese allergy announcement. Nothing is worth gaining a new cheese allergy, y’all. And that’s why we’re covering these steroid side effects in black and white, slow mo, normal size font.

    Steroids May Cause Tendon Rupture

    I say that with some ambiguity, because no study confirms that steroids directly cause tendons to explode. But if you take a look at this small sampling of quotes, all from scientific publications, you’ll notice a disturbing trend.

    Glucocorticoid-induced tendon rupture is very common in clinical practice.

    Corticosteroid injection is commonly used to treat tendon injuries but is often associated with tendon rupture and impaired tendon healing

    It is clear that the local administration of glucocorticoid has significant negative effects on tendon cells in vitro.

    Serious adverse effects have been reported as a result of [corticosteroid] treatment, such as impaired tendon healing and tendon rupture.

    Every one of those quotes links out to the associated study, because references matter, y’all.

    Steroids Damage Tendon Cells

    Now that you’ve seen the headlines, let’s get a little more specific here so you can weigh the evidence properly.

    • This review of 13 studies says tendon rupture and atrophy happen more frequently after steroid injection than placebo
    • This one  says that two different types of steroids decreased the tendency of tendon stem cells to become tendon cells (that’s bad) and slowed down the rate of cell growth (also bad).
    • In this study, even the lowest steroid dose increased expression of “dormancy” genes. So basically the cells go into retirement and stop doing the thing they’ve done their whole lives. It sounds like a great vacation for those cells, but your tendon might explode as a result.
    • In this study, steroids killed human tendon cells, decreased their ability to make new cells, and slowed collagen production.
    • In this one, steroid treatment decreased live cells and collagen production for at least two weeks.

    I left a longer list of references at the end of this post. Just in case you want to really dig in to this one rabbit hole. But even if you don’t read any further, the trend should be clear. Steroid injection leads to cell damage and tendon rupture. 

    But tendons aren’t the only thing steroids mess up.

    Steroids Damage Cartilage

    These poor horses had steroids injected repeatedly for two months, and it just damaged their cartilage. The study tested the mechanical properties before and after the injection cycle. And it turns out that the steroids made the cartilage weaker, more permeable, and thinner.

    This giant study (of other studies) offered a literal smorgasbord of cartilage damage:

    • 6 studies | loss of collagen organization
    • 3 studies | collagen loss
    • 17 studies | decreased collagen production

    In another big study (of other studies), the authors had this to say about normal clinical doses of steroids :

    …corticosteroids were associated with significant gross cartilage damage and chondrocyte toxicity

    So steroids hate basically all the tissues in your joints and want them to die. That’s the moral of the story so far.

    Steroids Aren’t Worth It

    Sure you get short term pain relief. But at what cost? Is four weeks of pain relief worth speeding up the breakdown of your cartilage and tendons? Or the risk of literal tendon explosion*?

    *no, they don’t explode like fireworks. But every time I read “tendon rupture” I imagine one of those coyote and roadrunner BAM signs appearing. So I stand by my decision to call it an explosion on cartoon-related principles. #IDoWhatIWant

    Back to the ranch – are steroids worth the risk of completely messing up your joint/tendon?

    I don’t think so, and that’s why none of the people I love ever get the green light from me when they ask about steroid injections for joint pain.

    Now, qualifier: there are cases in which steroids are absolutely necessary. Sometimes inflammation gets so out of control that steroids literally save lives. But looking at your everyday average arthritis related joint pain, you should run as fast as you can in the opposite direction of steroids. Possibly in the direction of some of these joint friendly alternatives.

    There Are Steroid Alternatives

    Hyaluronic acid, platelet rich plasma, and bone marrow concentrate all have associated clinical studies that show significant pain relief. Without the tiny side effect of aggressively maiming all the cells you’re trying to fix in the process. And they take about the same amount of time as a steroid injection.

    So next time someone recommends steroids for your joint pain, ask if they have an alternative that isn’t terrible. Because getting a steroid injection for arthritic joint pain is like going to a loan shark to pay off your bookie. (Yes, y’all, I do watch a lot of CSI.) Your problem goes away temporarily, but two weeks later you’re way worse off than before.

    So why shouldn’t you get steroids for joint pain (unless you absolutely have to)? Because they literally damage your joint tissue and lead to more pain.

    Alright kids, that’s it for this soapbox. For more information, feel free to browse the list of references below. If that’s not your style, leave a comment or drop me a line.

    References No One Wants To Read

    1. Murray RC, Debowes RM, Gaughan EM, Zhu CF, Athanasiou KKA. The effects of intra-articular methylprednisolone and exercise on the mechanical properties of articular cartilage in the horse. Osteoarthr Cartil. 1998;6(2):106-114. doi:10.1053/joca.1997.0100
    2. Zhang J, Keenan C, Wang JH-C. The effects of dexamethasone on human patellar tendon stem cells: Implications for dexamethasone treatment of tendon injury. J Orthop Res. 2013;31(1):105-110. doi:10.1002/jor.22193
    3. Nuelle CW, Cook CR, Stoker AM, Cook JL, Sherman SL. In Vivo Toxicity of Local Anesthetics and Corticosteroids on Chondrocyte and Synoviocyte VIability and Metabolism.
    4. Dean BJF, Lostis E, Oakley T, Rombach I, Morrey ME, Carr AJ. The risks and benefits of glucocorticoid treatment for tendinopathy: A systematic review of the effects of local glucocorticoid on tendon. Semin Arthritis Rheum. 2014;43(4):570-576. doi:10.1016/j.semarthrit.2013.08.006
    5. Spang C, Chen J, Backman LJ. The tenocyte phenotype of human primary tendon cells in vitro is reduced by glucocorticoids. BMC Musculoskelet Disord. 2016;17(1):1-9. doi:10.1186/s12891-016-1328-9
    6. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010;376(9754):1751-1767. doi:10.1016/S0140-6736(10)61160-9
    7. Fredriksson M, Li Y, Stålman A, Haldosén LA, Felländer-Tsai L. Diclofenac and triamcinolone acetonide impair tenocytic differentiation and promote adipocytic differentiation of mesenchymal stem cells. J Orthop Surg Res. 2013;8(1):2-7. doi:10.1186/1749-799X-8-30
    8. Yang, Shu-long, Yu-bo Zhang, Zhi-tao Jiang, Zhao-zhu Li and DJ. Lidocaine Potentiates the Deleterious Effects of Triamcinolone Acetonide on Tenocytes. Med Sci Monit. 2014;20:2478-2483. doi:10.12659/MSM.891116
    9. Chen W, Tang H, Zhou M, Hu C, Zhang J, Tang K. Dexamethasone inhibits the differentiation of rat tendon stem cells into tenocytes by targeting the scleraxis gene. J Steroid Biochem Mol Biol. 2015;152:16-24. doi:10.1016/j.jsbmb.2015.04.010
    10. Scutt N, Rolf CG, Scutt A. Glucocorticoids inhibit tenocyte proliferation and Tendon progenitor cell recruitment. J Orthop Res. 2006;24(2):173-182. doi:10.1002/jor.20030
    11. Poulsen RC, Watts AC, Murphy RJ, Snelling SJ, Carr AJ, Hulley PA. Glucocorticoids induce senescence in primary human tenocytes by inhibition of sirtuin 1 and activation of the p53/p21 pathway: In vivo and in vitro evidence. Ann Rheum Dis. 2014;73(7):1405-1413. doi:10.1136/annrheumdis-2012-203146
    12. De Mos M, Koevoet WJLM, Jahr H, et al. Intrinsic differentiation potential of adolescent human tendon tissue: An in-vitro cell differentiation study. BMC Musculoskelet Disord. 2007;8:1-12. doi:10.1186/1471-2474-8-16
    13. Zhang J, Wang JHC. Characterization of differential properties of rabbit tendon stem cells and tenocytes. BMC Musculoskelet Disord. 2010;11. doi:10.1186/1471-2474-11-10
    14. Wernecke C, Braun HJ, Dragoo JL. The effect of intra-articular corticosteroids on articular cartilage: A systematic review. Orthop J Sport Med. 2015;3(5):1-7. doi:10.1177/2325967115581163

    Photo by Justyn Warner on Unsplash

  • How Are Stem Cells Used Now?

    Y’all. If I get one more question about commercials for stem cells fixing intimate issues or stopping the aging process… I will complain aggressively to all my friends. Again.

    It seems like we, humans, have a super obnoxious habit of discovering something awesome and then over-selling it. Did those Ron-Popeil dehydrators ever really make anyone healthier or more energetic? Sure, fruit leather is tasty, but it’s not really altering the status of my tax return or removing all the pro-diabetes DNA from my genome.

    I find it easy to forgive the people at RonCo, because they just sold dehydrators for five easy payments of $9.99. I find my forgiveness skills far more challenged when people start selling stem cells for real problems that they absolutely do not address at this point in time.

    Stem cells do not at this time treat autism. Or cerebral palsy. Or irritable bowel syndrome.

    True story: when I was a wee small child in med devices, I volunteered at a stem cell charity event. And this guy told me that he had gotten shark stem cells in Mexico that cured his IBS.

    I am happy for this man, because IBS makes people miserable. But also, shark stem cells did not cure his IBS.

    Stem cells do address a number of issues though. So let’s dig in and see where physicians use stem cells right this moment.

    Spoiler alert: concentrated bone marrow (containing mesenchymal stem cells) is the most common form of clinical stem cells right this moment.

    Stem Cells From Concentrated Bone Marrow Help Grow Bone

    You’re probably thinking people don’t generally have trouble growing bone. Usually they just fall horrifically from one of those obnoxiously placed rent-a-scooters, snap their radius (forearm bone), pay way too much money for urgent care, get a puke green cast, and then magically have intact bone a couple months later.

    But things don’t always work out that way. Sometimes our bodies get tired of all the abuse and stubbornly refuse to grow back that broken bone.

    Non-Union Fractures: When Bones Just Can’t

    When this happens, the medical community calls it a non-union fracture. It means your body got stalled halfway to fixing that bone, and instead of bone, you get a type of cartilage.

    In the United States, this problem often receives an invasive surgical remedy, but the lovely French doctor I’ve mentioned in a couple of other posts has a simpler solution. For appropriate patients. He uses concentrated bone marrow (containing mesenchymal stem cells) to treat non-unions in average patients, diabetic patients, and even patients whose non-unions are infected.

    Without additional surgery or plates and screws. Just an injection of concentrated bone marrow.

    And it’s not just him. Many US surgeons now offer this option instead of surgery, because it carries less risk and requires less downtime for the patient.

    I have to point out that this isn’t new-fangled technology. The first publication I linked is literally 13 years old. Dubbya lived in the White House back then. So… mesenchymal stem cells have been helping heal broken bones since all of us were living in a very different world.

    Spinal Fusion: Don’t Let Your Hip Pay The Price

    During spinal fusion, a surgeon attempts to replace what they consider malfunctioning soft tissue in the spine with new bone. In ye olden days of spinal surgery, they used to harvest a big chunk (yes, that’s the technical term) of bone from the hip and put it in the spine. For a certain number of patients, this chunk o’ hip would leave them with long term pain.

    How might we fix this?

    Well, we could use concentrated bone marrow again. And it turns out that spine surgeons all over the world do this all the time now, and it works great.

    Plus, patients experience fewer complications and less pain with bone marrow aspiration than with chipping off a chunk of the old hip bone.

    Stem Cells From Concentrated Bone Marrow Help With Knee Stuff

    Sadly, there are a million reasons you might have knee pain. Maybe you played tennis too much in high school. You might have raced your college roommate up the stairs too many times. Or maybe you’ve just been living that rockstar lifestyle too long, and now you’re paying the price.

    Whatever the reason, and however metal it may be, most of us end up with knee pain at some point. So it qualified as good news for me when I finally saw publications coming out about mesenchymal stem cells being used for knee pain. As of right now, here’s where we see them clinically:

    1. Knee Arthritis
      In this study, patients reported improved function and reduced pain after injection of concentrated bone marrow.
      In this 125 patient study, patients experienced an average 71.4% decrease in pain. <– This one also used PRP.
    2. Osteochondral Defects
      *Osteochondral defects happen when joint injury goes all way from the top cartilage surface down to the bone. So both the cartilage and the bone need repairing.
      This study, this one, this one, this one, and this one all used concentrated bone marrow to successfully treat osteochondral defects. I actually don’t have room or time to list all the studies like these. But I do have to say that most of them show superiority of the bone marrow (mesenchymal stem cell) based treatment versus the alternative.
    3. As An Alternative to Total Knee Replacement
      In this landmark study, 30 patients who could have had double knee replacement surgery instead got one knee replacement and one bone marrow concentrate treatment with mesenchymal stem cells. Pain relief was roughly equal for the knee replacement vs. the bone marrow concentrate knee. And more importantly, 21 of the 30 patients preferred the bone marrow concentrate knee to the knee replacement. Probably on account of the easier recovery and fewer side effects.

    Stem Cells From Concentrated Bone Marrow Help With Hip Osteonecrosis

    Y’all, the privilege of advancing age brings a lot of awesome things. Holographic assistants, Snap Chat filters, and that peanut butter with the jelly already swirled in it, just for starters. But other stuff comes too. The undeniable urge to tell kids to get off your lawn suddenly overwhelms you. Yes, even when you don’t have a lawn. You start saying things like “my dress yoga pants” and “oooh, 9:30 on a weeknight is pretty late.”

    And sometimes your body betrays you and forgets to supply blood to things you feel are fairly vital.

    No, not that thing. You’re looking for a different website altogether if you want to discuss that thing.

    Over here at ISY, I’m talking about your hip joint, specifically the moving part of it.

    When your body fails to bring sufficient blood supply to that bone, it can deteriorate, causing pain and dysfunction. This condition is called osteonecrosis of the femoral head, and it sucks. And is one of the leading causes of hip replacement.

    But not to worry, concentrated bone marrow has treated this condition for more than thirty years now. Just check out this ridiculous list of studies:

    Stem Cells from Concentrated Bone Marrow Help Shoulders

    Rotator cuff repair surgery has a shockingly high failure rate. Of course the failure rate depends on a number of factors. Regardless, 20-50% failure rates would upset even the most unflappable patients.

    Don’t worry though. As with every section in this post, stem cells come to the rescue.

    In this study, bone marrow treated rotator cuff repairs healed faster and were almost twice as likely to remain intact after ten years.

    In this other study, they found concentrated bone marrow effective in reducing pain and improving function in rotator cuff tears.

    Stem Cells from Concentrated Bone Marrow Help Cartilage

    I’ve actually already covered this in the knee section with osteochondral defects, but let’s revisit. Because osteochondral defects, though doctors never call them that to your face, happen more often than you’d think. Mostly in knees and ankles though.

    Osteochondral Defects Happen

    This may seem irrelevant, but just go with me for a second:
    When I was doing gymnastics in the wilds of central Texas, we used to do this super dumb thing called mat crew. See, my high school couldn’t afford a real foam pit for training. So instead, we would make four gymnasts literally hold a big crash mat in the air and try to “soften” the landing for another gymnast throwing a big trick.

    No, it was totally safe, y’all. And also how I dislocated my ankle and become the proud owner of my very own osteochondral defect. I wasn’t sure if I should be proud of losing 40% of the cartilage in my ankle or terrified of it. It sounded kind of epic, but then…

    My pediatric orthopedic surgeon told me, in words I’ll never forget, that I should probably quit gymnastics. And that I was definitely not doing any other sports or running ever.

    You do not run. You do not jump. You do nothing that involves impact on this ankle. You can finish your last two years of gymnastics, but after that it’s over. Unless you want to have arthritis so bad that you feel crippled by the age of 30.

    That’s what he said to me. At 16 years old. And he was right, but he didn’t have concentrated bone marrow back then. And it would have made a world of difference.

    Concentrated Bone Marrow Is Awesome for Cartilage

    Since I’ve already written way too much here, I’m just going to leave you with this list of publications making my point for me. Every one of these publications says I could have run, jumped, and generally abused my ankle for years after that fateful mat crew incident. If only my surgeon had been able to use concentrated bone marrow.

    1. 2010 Study | Knee Cartilage
    2. 2011 Study  | Knee Cartilage
    3. 2011 Study | Knee Cartilage
    4. 2013 Study | Knee Cartilage
    5. 2014 Study | Knee Cartilage
    6. 2015 Study | Knee Cartilage
    7. 2016 Study | Knee Cartilage
    8. 2016 Study | Knee Cartilage
    9. 2017 Study | Knee Cartilage
    10.  2009 Study | Ankle Cartilage
    11.  2010 Study | Ankle Cartilage
    12. 2011 Study | Ankle Cartilage
    13. 2011 Study | Ankle Cartilage
    14. 2013 Study | Ankle Cartilage
    15. 2014 Study | Ankle Cartilage
    16. 2016 Study | Ankle Cartilage

    That was a lot of studies, y’all. But I have one more thing to share, one more clinical use of stem cells that happens pretty much daily in this country.

    Stem Cells from Concentrated Bone Marrow Help Back Pain*

    *A very specific type of back pain called discogenic back pain.

    Please note: that doesn’t mean all kinds of back pain. There are some kinds of back pain, like those resulting from CRPS or other types of nerve injury that probably won’t respond to any currently available stem cell treatment.

    Stem cells aren’t magic, y’all.

    But they have treated discogenic back pain. This study showed a 70% average pain reduction at 3 year follow-up after discs were treated with concentrated bone marrow. And the patients in that study were all spinal fusion candidates. So with 70% pain relief, most of them chose not to go on to surgery. That’s huge in my book.

    This last application has the fewest publications, but we’ll see a lot more in the next couple of years. Because physicians are offering this therapy a lot more than they’re publishing it. I still wouldn’t say this qualifies as a super common use right now, but it is definitely clinically available.

    Well That Took Forever

    When I started this post, I told myself it would be a short one. :: haha ::

    Let’s focus on the positives though. Now you know how stem cells are used clinically today. In orthopedics.

    That’s an important caveat. I skipped over stem cells in cancer and immunotherapy. I’ll have to cover those in another post, because this one is already out of control.

    Do you know someone who received a stem cell treatment not listed here? Have questions about any of the million things I said?

    Get your two cents into the comments, or leave some feedback directly in my inbox!

    Photo by rawpixel on Unsplash

  • Parkinson’s Disease: Can Stem Cells Help?

    Parkinson’s Disease is serious, y’all. And I don’t really like to write about serious things, because they’re real. They impact people’s lives. And break hearts. And test limits. And forge humans out of steel.

    But today I’m going to discuss Parkinson’s Disease, because someone emailed me about it a week ago. And I don’t believe they’re alone in their line of questioning. And really this is why I made this blog. It can’t always be the top five reasons you shouldn’t listen to Gwyneth Paltrow about literally anything outside of hair care.

    Here’s what you need to know: the malfunction that causes Parkinson’s, how we currently treat it, and whether or not it makes sense to use stem cells (or other cutting edge technologies) to improve upon current treatments.

    So let’s jump right in.

    Parkinson’s Disease Lives In A Small Cell Cluster

    in the brain. Even now, as an all grown-up scientist minded person, I find it hard to believe that such a tiny structure can cause such big problems. But it does.

    This awesome animation from Khan Academy does a great job of explaining the crux of the issue. At least the part of it that we understand. In a nutshell, this small cell cluster in the mid-brain, the substantia nigra, loses cells that make dopamine. The decrease in dopamine leads to the physical symptoms of Parkinson’s Disease, like tremors and slow/difficult movement.

    So really, Parkinson’s Disease comes down to brain cells dying when we really need them to stay alive and keep making dopamine. But there is good news:

    We Have Great Medications for Parkinson’s Disease

    Even though Parkinson’s is a progressive, degenerative condition, we do have awesome medications for it. See, we know that loss of dopamine is the biggest issue. And physicians have actually been treating that symptom of PD for over forty years in a couple of different ways.

    Dopamine Agonists

    These are sort of the expendable crewmen of Parkinson’s treatment. Dopamine agonists have some of the same effects as dopamine and can control the early stages of Parkinson’s symptoms. And there are so many of them that I’m not going to bother listing any.

    Long story short: dopamine agonists comprise the first line of Parkinson’s defense and can work well in the early stages after initial diagnosis.

    L-Dopa

    Y’all know your brain runs your whole body, right? So your body has several ways of protecting it, one of which is the blood-brain barrier. This intricate biological system guards the  brain, much like the kind of security you’d expect to see in important government buildings. Only things that really need to be in the brain get through.

    So if we want to put dopamine in the brain to treat Parkinson’s, we have to find a way to get it past the blood-brain barrier. Because the brain thinks dopamine comes from the brain, so it doesn’t have a natural mechanism for allowing it past the barrier.

    That’s where this awesome molecule (that I used SO much in grad school) comes in. Levodopa, or L-Dopa, easily crosses the blood-brain barrier and is converted to dopamine in the brain. Which then leads to a decrease in Parkinson’s symptoms.

    But. Only a small percentage of L-Dopa crosses into the brain, leaving the rest of it bumping around in parts of the body where it isn’t needed. And can cause unwanted side effects when it converts to dopamine.

    So for Parkinson’s, L-Dopa usually comes with a couple of other drugs that (1) don’t cross the blood-brain barrier, and (2) prevent the conversion of L-Dopa to dopamine. This way you get more dopamine in the brain, where it’s needed, without getting more dopamine in the rest of the body where it’s not.

    Now, as with many things in your body, continued use of L-Dopa combined with progressive loss of dopamine producing cells can lead to “tolerance” of lower doses. So most patients will end up increasing their dosage over time, eventually leading to a point at which they are experiencing unwanted side effects due to the high dosage.

    This is usually the point at which patients begin looking at more aggressive treatment options, including the addition of some of the prescriptions below.

    Others

    MAO-B Inhibitors: MAO-B stands for a really long enzyme that breaks down dopamine. When we inhibit that enzyme in the brain (with MAO-B Inhibitors), dopamine should stick around more. And symptoms of Parkinson’s should decrease. These guys do present more of an issue though, because they cause more side effects than dopamine agonists.

    COMT Inhibitors: You probably guessed it, but COMT is short for an enzyme that breaks down dopamine. So same story here as directly above. The idea is to inhibit the thing breaking down dopamine, thereby increasing dopamine. These are used less frequently than other options due to side effects and lack of efficacy.

    Physicians may also treat psychosis, dementia, and excessive sleepiness with a cocktail of other drugs. But those are really aimed at some of the downstream effects of Parkinson’s and not the cause (lack of dopamine).

    So what happens when a person has been treated with these great drugs for so long that they’re no longer effective?

    Physicians and patients start looking into surgical answers. And the surgical answers are pretty remarkable.

    We Have Awesome Surgery for Parkinson’s Disease

    Remember earlier how I said that PD comes from a tiny cell cluster in the brain? I’m going to see if this link will show you that cell cluster.

    Side note: my single favorite way to understand anatomy is Zygote Body. It really helps visualize some of the things, especially brain structures, that are hard to understand without three dimensional information. 

    Ok, that link won’t show you what I want. But, if you click the link and then type “substantia nigra” into the search bar on the top right, it’ll label the right structure for you.

    Ok, now that you’ve seen the size of this cell cluster, let’s move into how the surgical option works. No, surgeons don’t implant a time release dopamine device. Or nanobots that make dopamine.

    It turns out that electrical impulses can actually make up for the loss of dopamine. Crazy, right?

    But not really. Because almost every cell in your body depends on very tiny electrical impulses. So even though dopamine is the problem, electrical stimulation can be the solution. Because when functioning correctly, the dopamine should control electrical impulses in charge of physical movement (in that part of the brain).

    If electrical impulses work, then how do we get them into the Parkinson’s causing part of the brain?

    surgeons Place Tiny Implants In The Brain

    You read that right. I know it sounds scary, but surgeons have gotten really good at this. Plus the implant itself is like a piece of cooked spaghetti. Here’s how it works:

    1. Doctors take a ton of pictures of your brain and map out every blood vessel, structure, and fold.
    2. Doctors use all of those pictures to make a 3D model of your brain.
    3. Using the 3D model, a pathway is marked out from your skin all the way to the target cells. This pathway avoids all important structures and essentially makes a beeline direct from your skin to the target location.
    4. At the beginning of surgery, you put on a special crown. This crown orients your brain in surgery to the pictures of your brain in the 3D model. That way the surgeon is certain that the planned starting and ending points are exactly the same in surgery as in the plan.
    5. Once surgery begins, your surgeon uses a robot to slowly guide the tiny spaghetti like implant down the planned path.
    6. As the final location approaches, your surgeon will test the implant. So yes, you’ll be awake. This testing phase ensures that the implant is in the most beneficial location for your specific brain anatomy.
    7. Once the surgeon finds the optimal location, they attach the spaghetti to a tiny anchor just outside your brain. This keeps the implant still and ensures your movements don’t ever affect the implant location.
    8. The last part of surgery is attaching the end of the piece of spaghetti to a small battery, and then implanting that battery. Most people put the battery in their chest or abdomen, and they’re so small now that you really have to know where they are to find them. Much like pacemaker batteries.

    Here’s a creepily silent animation that shows an example of where this type of implant goes.

    Now, because this implant requires brain surgery, the surgeon doesn’t turn it on immediately. So even though it’s physically in the right place, most surgeons will wait a couple of weeks before turning it on. This ensures that your body has had time to calm down after surgery.

    Once those couple of weeks pass after surgery, a neurologist will program the implant. This process just tells the implant how much electricity to use in which part of the implant to give each patient the best result.

    So what is that best result?

    Brain Implants Are Crazy Effective

    This video demonstrates how incredible these implants are. And he comes right out and says it.

    It’s life changing.

    But wait – where’s the science? Ok, let’s check the literature to see how effective these implants really are.

    In this review, published this year, the authors looked at twelve different studies including 401 patients. They wanted to see if the effects of L-Dopa and brain implants were better together or possibly separately. They found, as you might expect, that both treatments decreased the physical symptoms of PD. But, when used together, patients experienced a 35 point improvement on a Parkinson’s Disease rating scale versus only about a 20 point improvement when either treatment was used separately.

    That’s on the order of 50% more effective when combined than when  used separately.

    Note: this review article included data up to five years out from surgery. And, some of the implants used would have been less advanced than the ones we have now. So I personally would expect some patients to have even better outcomes than what this review included.

    Stem Cells for Parkinson’s Disease?

    I know I’ve just sold you on the epic nature of brain implants for Parkinson’s. And you’re probably thinking we don’t need stem cells anymore. Especially if you watched this video all the way through. But, let’s revisit one important point.

    Every treatment I’ve listed thus far treats a symptom of Parkinson’s Disease, not the underlying cause. Which means that every treatment, even life-altering brain implants, doesn’t really present a solution.

    That’s where people tend to lean toward stem cells. Because they can become other kinds of cells, right? Like maybe dopamine producing cells?

    Maybe. At this time, I’m not aware of anyone actually creating dopamine producing cells from any adult stem cell. But that doesn’t mean it’s not happening. It might be. [edit: it is happening. Here. And here.]

    Let’s focus on a more realistic role for adult stem cells though. Remember when I listed the functions that make mesenchymal stem cells (MSCs) so useful? Let’s speculate wildly* for a moment about how those properties might help with Parkinson’s Disease.

    *Note: wild speculation is not science. It is the combination of imagination with substantial education. So wild speculation may turn out to be true, and it may not. You’ve been warned. 

    Now back to that speculation.

    Ways MSCs Might Help with Parkinson’s
    1. MSCs save dying cells. Dopamine producing cells die in PD, causing physical symptoms.
      Maybe MSCs could save some of those cells, slowing down or stopping the progression of PD at the root.
    2. MSCs control inflammation. Inflammation occurs in the same area in which dopamine producing cells die. Some researchers have even declared that inflammatory processes are “crucial for disease progression.”
      Maybe MSCs could control or eliminate the inflammation, thus depriving the tissue of one crucial component for PD progression.

    But what about other stem cells? Could they help too?

    Maybe.

    And you’ll find the mechanism of their help pretty obvious. Other stem cells, possibly manipulated MSCs or iPS cells (which I’ll still talk about in a later post) could maybe be programmed to produce dopamine. Basically these manipulated stem cells would attempt to replace the damaged or dead cells in the brain. And as such could represent a more long-lasting treatment option than some of the pharmaceuticals currently in use.

    But that goes for all of the cell-based treatments. Any time we can get a living cell to go stay in a damaged tissue and do the job that tissue needs, that solution lasts longer than any non-cell based solution. Because cells maintain themselves much longer than any implant or drug can.

    Alright. Now that we’ve speculated wildly, let’s take a look at what people have actually done with stem cells and Parkinson’s Disease.

    Stem Cells Have Been Used to Treat Parkinson’s Disease

    In 2010, this group published a study with follow-up at the three year point for some of their patients. Now, you must pay attention to how they implanted the cells here, because they did it right. This group used the same brain surgery approach I described earlier for those spaghetti noodle implants, but instead of those implants, these guys placed MSCs from the patient’s bone marrow in the target area.

    very important note:

    Every time someone uses stem cells, or a drug, or anything to treat anything in the human body. In order for it to work, they must first figure out how to get it where it needs to go.

    So when someone says they want to treat Parkinson’s Disease, they need to figure out how to get their treatment into the specific area of the brain where we know the cells are dying.

    And that’s a challenge. Because the blood-brain barrier is legit. It lets very few things pass. Imagine it as Gandalf just constantly yelling YOU SHALL NOT PASS at almost everything. Including stem cells. Stem cells CANNOT pass the blood-brain barrier. They’re too big.

    So when you read about someone using stem cells to treat Parkinson’s Disease, you should be looking for an actual brain surgery to get those cells where they need to be.

    end very important note

    As I was saying, this group did it right. They used brain surgery, just like the one used for PD electrical spaghetti noodle implants, to get the cells where they needed. Three of the seven patients treated showed steady improvement in the Parkinson’s Disease Rating Scale assessments, improving on average 22.9% from before treatment. Two of those patients also significantly reduced their medications.

    Members of that same group did another study in which 12 patients ranging from 5 – 15 years after PD diagnosis were treated with MSCs not from their own bone marrow. Again, this group implanted the cells using an appropriate brain surgery technique. One subset of patients, basically with standard PD diagnosis, improved 17.92% during “on” (meaning effectively medicated) state and 31.21% during “off” state. But some of the patients in this study didn’t improve at all.

    And that’s one of the things about early research. We don’t always know why certain patients didn’t respond. Eventually an explanation will surface. But we have to do more studies to figure that out. And eventually we’ll get more patients with improvement and less patients who just don’t respond. Or at least we’ll be able to better predict when patients aren’t good candidates.

    Let’s talk about one last study real quick. This one used highly manipulated stem cells programmed to become neural stem cells. The researchers used the same brain implantation technique we’ve discussed to place the neural stem cells in the brains of African green monkeys with Parkinson’s Disease. Twelve months after implantation, the monkeys had behavioral improvements, increased dopamine levels, and increased numbers of dopamine producing neurons.

    I know this research sounds cool, and I’m hopeful that we’ll see some of the MSC based therapies in the regular world within the next ten years. The results thus far are definitely promising.

    But. Right now this stuff falls into the research category. It’s not ready for prime time yet.

    It will be. In our lifetimes. Just not right now.

    People Should Not Be Selling Stem Cells for Parkinson’s Disease

    Did you notice the common thread among the studies I covered? Every single one of them used brain surgery to place the cells. Right now, that’s the only surefire way to get stem cells to the tissue affected by Parkinson’s Disease.

    So if you happen to search for a PD treatment and find someone offering stem cells for it, I hope you’ll first check to see if they’re a neurosurgeon. Specifically one specializing in stereotactic brain surgery (the technical term for the type of surgery we’ve discussed multiple times in this post).

    If a chiropractor, pain management doctor, orthopedic surgeon, witch doctor, naturopath, shaman, priest, or alien offers you a stem cell treatment for PD, please don’t mortgage your house for it. Please don’t use your kid’s college tuition for it.

    Please ask a thousand questions, the most important of which are: how will this get to my PD cells? How many times have you done this before, and what were the results? Is this part of a clinical study? How do you know this is safe?

    If someone offers you or a loved one a stem cell treatment for PD outside of a clinical trial or study, without the help of a neurosurgeon, you should not expect success. Or safety.

    In case there’s any lingering doubt, my personal favorite PD treatment is the electrical spaghetti noodle implant. They do amazing things and have a long history of safe and effective use.

    I’m excited to see stem cells come onto the PD field in the near future. I really am. But I know they aren’t ready for general clinical use in Parkinson’s Disease just yet.

    Have you heard of any other cutting edge PD treatments? Or something crazier than stem cells that you think is a pack of lies? Let me know in the comments, or send that info direct to my inbox!

  • Adult Stem Cells: What Are They Anyway?

    Adult stem cells pop up everywhere in the news, and yet, much like most of politics, it’s hard to tell what’s really going on with them. So today I’ll explain the most important adult stem cell concepts for you, the everyday, non-scientist, healthcare consumer. And hopefully won’t bore you to tears in the process.

    “Adult Stem Cells” Is A General Term

    In my last post I shared the earth shattering fact that “stem cell” is a very broad term, and unfortunately “adult stem cell” has that same designation. Recall that a stem cell, by definition, is any cell capable of copying itself and turning into a different kind of cell.

    A regular old stem cell that happens to be found in an “adult” tissue qualifies as an adult stem cell. And the whole adult designation misleads a bit, because it gives the impression of a stem cell found only in adults. But adult stem cells can be found in infants, the oldest person in the world, and everyone in between. Even Keith Richards.

    Now, I know you’ve memorized every word of my last blog post. So I don’t need to mention the fact that adult stem cells are found in almost every tissue in your body. And we can just move onto the most important kind of adult stem cell, the mesenchymal stem cell.

    Mesenchymal stem cells are the adult stem cell you hear about most frequently right now. But why?

    Mesenchymal Stem Cells Are The Most Useful Adult Stem Cells*

    *Currently.

    I briefly touched on this topic in my last post, but I need to expand. Because these special adult stem cells are awesome.

    Mesenchymal stem cells (MSCs) show up for the first time during embryonic development. In this cute animation, early stage embryonic stem cells separate into three layers: ectoderm, mesoderm, and endoderm. We care about the mesoderm layer, which creates muscle, blood and blood vessels, bone, and connective tissue.

    During this super complicated process that somehow builds a complete human being almost every single time it happens, the stem cells from the mesoderm don’t disappear. Instead, some remain inside bones and hanging onto the outsides of blood vessels throughout the body, for literally the rest of a person’s life.

    These stem cells that came from the mesoderm and made the daunting commitment to stay with us our whole lives are mesenchymal stem cells.

    I know, a lifelong commitment seems pretty extraordinary. That must set them apart from all the other stem cells, right?

    Didn’t Benjamin Franklin say that 80% of success is just showing up? This must be what he was talking about, eh?

    Not exactly. First of all, Benjamin Franklin definitely didn’t say that. And second, MSCs have a variety of properties that make them A) wildly different versus other types of stem cells, and B) very powerful.

    Surprisingly, most of those properties aren’t the thing most of you are thinking. You know, the thing where MSCs can make muscle, blood, blood vessels, connective tissue, and bone? Right, not that thing.

    I’ve already mentioned the most useful characteristic of MSCs (in this other post): they live and function in the human body during every stage of development. So when we use them medically right now, they have all the signals they need to function correctly*.

    *When they come from your body and then go to work in your body. If they come from someone else’s body, that’s a different story.

    But, MSCs do so many other helpful things that they almost seem magical. Almost.

    Let’s dig into those other properties so you can love MSCs as much as I do. And know when they might come in handy.

    MSCs: Adult Stem Cells That Can Make Several Types Of Tissue

    In humans ranging in age from embryo to centenarian, MSCs live in bone marrow and on blood vessels. That means you can find them scattered throughout almost every part of your body.

    Despite living in so many places, MSCs still qualify as a rare cell type. They make up between 10 and 83 cells for every million cells in bone marrow and anywhere from 200 – 50,000 of every million cells in fat tissue.

    So how do they do such a great job making tissue if they’re so rare?

    Easy. They respond to homing signals.

    Remember how MSCs live in bone marrow and on blood vessels? That makes them sort of like the homeland security surveillance team of the human body. Except they’re more into tissue repair than stopping terrorism. See, MSCs are perfectly positioned to receive signals sent out by damaged tissue. And once they notice them, the MSCs follow those signals to their starting point where they then do the work of tissue repair.

    How do we know they actually make new tissue? Well this doctor used MSCs to repair broken bones, and this group used them to fix cartilage defects. This other group used them to repair cardiac tissue, and this one used them to grow blood vessels.

    And that’s just a tiny sampling of MSCs creating new tissue in real live humans.

    But MSCs do way cooler things that make them the best of the adult stem cells. So let’s talk about those!

    MSCs: Adult Stem Cells That Decrease Scarring

    We’ve all got scars, right? And I’m not just talking about the emotional ones from learning that no real live person EVER has Disney character hair. Ever. I’m talking about the physical scars (that hurt so much less, Disney).

    My most annoying scar lives on my forearm where a piece of rogue chicken wire got me. It bled like a fire hose and scared the crap out of my mom. She thought amputation was inevitable. She wrung her hands and audibly worried about the number of stitches I’d need, but luckily her fears were unfounded.

    That tiny cut became a scar that hasn’t changed in the last twenty years.

    So what happened?

    This awesome TedEd animation explains the process and is much easier on the eyes than all my words, so take a gander.

    In short, my chicken wire gash didn’t finish healing. My skin went through all the steps of healing right up until the last phase, remodeling, and just stopped short. This is probably why my mom was always complaining about  me finishing projects.

    Anyway, scars are a real thing that happen to most of us, and can sometimes interfere with our day to day lives. You may just not like how a scar looks, or a scar may actually keep you from moving the way you want. Either way,

    MSCs are the adult stem cells that can save the day.

    When MSCs arrive at the source of the homing signals (broken or healing tissue), they dump proteins onto the cells around them. Some of those proteins help the cells in the area to create tissue more like the surrounding tissue. Less like my shiny smooth forearm scar.

    Other MSC proteins also decrease the activity of malfunctioning scar cells. That allows the correctly functioning cells to make more of the new tissue, resulting in a less scar-like scar.

    Researchers the world over are currently looking for ways to use this MSC skill to improve severe scar cases. And if you’re reading this right now, you’ll probably see the results of those efforts in your lifetime. #WhatATimeToBeAlive

    MSCs: Adult Stem Cells That Kill Germs

    I’ve mentioned the basic function of the immune system before, but let’s review. Your immune system has two basic jobs: (1) distinguish between things that are you and things that are not you, and (2) kill things that are not you.

    Sounds pretty simple, right? Well then why do we get infections?

    Well y’all, sometimes things don’t work the way they’re supposed to. You might accidentally encounter a terrifying and rare bacteria in your neighbor’s hot tub. (That’ll teach you to go hot tubbing after Kenneth Parcell told you hot is the devil’s temperature!) Or you learn the hard way that grandma was wrong, and that milk really was too far gone.

    The point is: sometimes your immune system needs an assist. And in some of those cases, MSCs provide the assist. MSCs can supercharge the activity of regular immune cells, and they can fight invading microbes directly. They’ve also been used together with another kind of immune system adult stem cell to cure infected bones, and it worked!

    I must have you convinced that MSCs are THE adult stem cell, but I’ve got two more cool properties to share.

    MSCs: Adult Stem Cells That Control Inflammation

    Inflammation is a natural part of healing. In fact healing can’t happen without inflammation. So why would we need to control it?
    :: coughs loudly ::

    Sometimes things don’t work the way they’re supposed to. Instead of channeling the body’s healing cells and proteins to repair and replace damaged tissue, sometimes inflammation just hangs out doing nothing. Except causing trouble.

    Don’t worry though, MSCs can wrangle their fair share of troublemakers.

    MSCs actually make more inflammation controlling proteins than I would ever list here. But just for scale purposes, let’s say it’s on par with the number of ice cream flavors you can find at a Baskin Robbins.

    MSCs are so good at controlling inflammation that they’ve been used (in very small studies) to treat inflammation related diseases like Crohn’s disease and Lupus.*

    *Please note, these are early stage studies and not currently available treatments. If you have Crohn’s disease or Lupus, remain incredibly skeptical of anyone offering you a stem cell based treatment. Unless you hear “this is experimental” and “it probably won’t work, but it might,” the treatment likely leans in the direction of shady. And if you’re not sure, just shoot me a message! (Using the contact form, definitely not a gun, please.) <– I’m in Texas, so I have to say it.

    MSCs: Adult Stem Cells That Rescue Other Cells

    I love weird things, y’all. People, places, books, phrases. If it’s weird, I’m probably into it. And that’s been true since long before I moved to Austin. So don’t go blaming that personality quirk on the city of weird, because it’s all me.

    This fact is relevant on account of this last property being my favorite. Because it’s pretty weird and unexpected.

    MSCs save dying cells. As a kid fascinated with biology and chemistry, I never dreamed there were cells bumping around inside our bodies just waiting to counsel other cells when they despair of life. And yet, that’s exactly what MSCs do.

    See, sometimes things change in your body temporarily. In a heart attack, part of the heart muscle doesn’t get enough oxygen, which makes those heart cells hit the self-destruct button. And just like every over-dramatic villain movie, once self-destruct mode activates, it can’t be undone. Even if the temporary change has been addressed, and the heart muscle has oxygen again.

    Unless.

    Yes, you guessed it, your new favorite adult stem cell can save the day again.

    MSCs do a couple of different things that de-activate a cell’s self-destruct mode. They directly touch dying cells (like a hug, but for cells!), and they make proteins that prevent self-destructing cells from finishing the job.

    Isn’t that cool?

    Sometimes the results after MSC treatment seem like they’ve lasted way longer than they should have. And I think this property accounts for that. By saving some of the dying cells, the MSCs have a much longer lasting effect on the tissue. Because those saved cells can live for months or even years in some cases, all the while contributing to better tissue function and a happier human owner.

    Alright y’all, that was a whirlwind. If you stayed with me this whole time, thanks for coming along!

    If you’re still with me, let’s walk back through all that info real quick. And probably leave you wondering why the next three sentences weren’t this entire post.

    Just a quick recap:

    Adult stem cells are regular stem cells found in an “adult” tissue, which means all humans have them.

    Mesenchymal stem cells are the most useful adult stem cells, because they live and work in our bodies at every stage of developmentthey make new tissue, decrease scarring, control inflammation, kill germs, and save dying cells.

    #DropTheMic

    #ItsScienceYall

    Do you have questions about adult stem cells that I didn’t answer? Or did I make things super confusing? Let me know in the comments, or use the contact form to complain directly in my inbox!

    Thanks for reading, y’all!

    Photo by Louis Reed on Unsplash

     

  • Are Female Doctors Better?

    Female doctors are better than their male counterparts under some circumstances, at least according to a study currently making the media rounds.

    No, seriously. According to science.

    Alright, don’t harpoon me for being an angry, militant feminist just yet. Let’s talk about this study first, and then you can be the judge.

    First, a little context.

    Women Are At Higher Risk Of Death After Cardiac Events

    This is a real thing, y’all. Women were twice as likely to to die after hospitalization for a heart attack in this study (from 1996). And the authors noted that women were generally not treated as aggressively as men. I.e. they were half as likely as men to undergo some of the more invasive but lifesaving procedures. <– statistically significant

    Women and elderly people received primary percutaneous coronary intervention – aka lifesaving procedure after heart attack – less often and later than men in this more recent study. <– statistically significant

    In another study, younger women and those with a specific arrhythmia were more likely to develop prehospital cardiogenic shock and less likely to be prescribed “evidence-based treatment at discharge.” <– statistically significant

    This one’s a bit of a head scratcher for me. Women were literally discharged without prescriptions, the same prescriptions that men with similar pathology were given. I honestly can’t imagine what’s responsible for that, but I’m sure some fancy psychologist can figure it out.

    Anyway, my point here is that science supports the idea that women really are at higher risk of death, and, honestly, receiving sub-standard medical care after a cardiac event.

    But that’s not the point of this post.

    Female Doctors (General Internists) Have Lower Readmission And Death Rates

    In unearthing the fact that women are at higher risk than men after cardiac events, researchers wondered what it meant about the treating doctors. What caused this gender disparity? So they did a little digging and looked at WAY more data than I ever want to. Thank goodness these researchers didn’t feel the same way though.

    In 2017 a group of investigators affiliated with Harvard Medical School published data examining a physician’s effect on patient mortality and their likelihood to return to the hospital. They included over 1.5 million individual hospitalizations, 18,000 female doctors, and 39,000 male doctors.

    Patients treated by female doctors were less likely to die (11.07% for female doctors vs. 11.49% for male doctors) and less likely to return to the hospital after treatment (15.02% for women vs. 15.57% for men). Both of these data points were statistically relevant, even though the raw difference was only on the order of 0.5% for both patient death and return to hospital.

    To put these small differences in perspective, the authors calculated the number of patients a female physician would need to treat before preventing one additional death or return to hospital vs. a male physician.

    Number of Patients To Prevent One Death: 233
    Number of Patients to Prevent One Return To Hospital: 182

    So these differences aren’t apparent unless we’re looking at pretty large volumes of patients, but those volumes exist in a lot of hospitals. Meaning that this trend really demands our attention and further investigation, which brings me to the study currently making the rounds.

    Women Treated By Male Physicians Die More Frequently

    than when they are treated by female physicians, according this this recently published study. The authors said, and this is a direct quote:

    female patients treated by male physicians were the least likely to survive an episode of care

    They also noted that patients treated by female doctors, in general, regardless of patient gender, were more likely to survive.

    This study involved 581,845 patient treatment episodes between the years of 1991 and 2010. In other words, this study brings the heat when it comes to sample size and duration. It’s no bubblegum investigation between two fifth graders. Which means there are a LOT of statistics.

    Researchers anaylzed this data six ways from Sunday. This paper has so many statistical references that I had to Google a couple to jog the cob-webby parts of my brain. And those part of my brain do not want to be jogged.

    The moral of the story though: the results are statistically significant. This publication represents another data point indicating that female patients are at higher risk than their male counterparts. Especially if a man treats them instead of a female doctor.

    But wait, there’s more!

    These researchers wanted to draw some conclusions about the root cause of this male/female difference.

    Male Physicians Who Interact More With Women Are Better At Treating Them

    than male physicians who interact less with women. Seriously, this study showed a trend toward decreased risk for women treated by male physicians as those male physicians’ level of interaction with women in general increased.

    Cue the laugh track now. I feel like I’m telling a story about the Rosetta Stone instead of trends in modern healthcare. Because it seems like female doctors have a secret decoder ring, and the men just don’t. It also seems like the decoder ring works with both men and women.

    Also, how funny is it to say – when men interact more with women, they’re better at communicating with them??

    That’s like saying, “It turns out children become better at language after they talk for a few years.”

    Communication Tutors For Med Schools?

    Maybe med schools will start teaching physicians how to communicate with women the way Rice University teaches their engineers how to communicate with humans. True story, as a freshman at Rice, I listened to a representative of the engineering department explain why everyone had to attend workshops put on by the Cain Initiative. Which, despite the name, is not a creepy cult that meets in the basement of Baker Hall, the most gothic dorm on campus.

    It boiled down to this. Engineers are unskilled at communicating with humans. Which puts them at a disadvantage in life, not just in the workplace. Rice wanted to ensure their engineers were good communicators, so they created a team of communications tutors. From freshman year on, all engineering students were taken by the hand, critiqued, coached, and forced to present endlessly.

    And not to brag, but it totally worked. When I came into grad school, I remember several people commenting on the quality of my slides and presentation style*. “You don’t sound like other engineers.” And not just because I talked way too much about Disney movies.

    So, Tracy Voss, maybe you could head over to Baylor and teach them a few things about remedial communication techniques for people who are naturally terrible communicators.

    *Y’all don’t judge Tracy Voss and Rice University on the quality of this blog. You can attribute all shortcomings to the fact that I was raised by wolves and am wildly unapologetic about that.*

    Advocate Assertively

    for yourself and/or your loved ones. That’s the moral of this story.

    Yes, it seems that male physicians communicate poorly with female patients, leading to increased mortality risk for those female patients. You can’t choose a female physician every time you need healthcare. So whether you’re a man or a woman, you need to communicate as clearly as possible any time you’re in need of healthcare. Especially anything urgent involving your heart, lungs, or brain.

    Don’t ever skip over information, even if you think it might not be relevant. And don’t be a hero. I was raised to suck it up and work through the pain. Bleeding hands? Do that bar routine anyway. Soles of your feet black and blue from an aggressive beam crash? You’re still vaulting.

    But I know now, from watching hundreds of cases and hearing about thousands, sucking it up is often bad for you. Now, you don’t need to whine about a paper cut. But, you do need to recognize that pain, even if you can handle it, is telling you something important about your body’s needs. And you need to listen to that, or at least communicate it to a physician. Clearly. And proactively.

    Female Physicians Are Better

    according to these studies anyway. But, that doesn’t mean they’re better scientists, or smarter. None of the studies I’ve mentioned, or the ones they reference say anything about raw talent or intelligence. In fact, they clearly state that we don’t know why female physicians appear to treat their patients more effectively than their male counterparts. Some of them suggest that it does indeed come down to communication.

    But at this point, we don’t know why. We only know that female patients are at a disadvantage when treated by male physicians. And as much as I dislike this data (because it kind of sucks for everyone), it’s still science.

    Do you have any suggestions for improved communication between physicians and patients? Sound off in the comments or send me a message!

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