We’re learning more about the growing field of orthobiologics, the use of treatments derived from individual patients’ own cells and injected at the injury site to promote healing. Dr. Allison Schafer, a nonoperative sports medicine physician at the UConn Musculoskeletal Institute, offers bone marrow aspirate concentrate, or BMAC, for this purpose. She joins Carolyn and Chris to explain how it works and what makes it effective.
(Dr. Allison Schafer, Carolyn Pennington, Chris DeFrancesco, December 2020)
Chris: What, if you could use your own cells to relieve pain and even heal injuries? On today’s Pulse, we learn about an advance in sports medicine that’s been shown do just that
This is the UConn Health Pulse, a podcast to help you get to know UConn Health, and it’s people, a little better, and hopefully leave you with some health information you’ll find useful too. Thank you for joining us. With Carolyn Pennington. I’m Chris DeFrancesco.
Now some injuries are treatable with an injection — cortisone, steroids or other drugs — but what about a concentration of cells derived from the inside of your hip?
Here to explain is Dr. Allison Schafer, a sports medicine physician at UConn Health’s UConn Musculoskeletal Institute. Good morning, Dr. Schafer, thank you for joining us.
Dr. Schafer: Good morning. Thank you for having me.
Chris: Cells derived from the inside of your hip, did I get that part right?
Dr. Schafer: Absolutely. Yes. It’s one of the new therapies that we’re discovering more in sports medicine and orthopedics, where we actually take bone marrow out of the side of your hip, spin it down and process it in a way that it can be injected back into your own body to help relieve various tendon and joint problems.
Carolyn: What is this therapy called, may I ask?
Dr. Schafer: Yes. So it’s called bone marrow aspirate concentrate. There’s also a similar condition where we can take stem cells out of the adipose tissue in your stomach. However, that one is a little more involved and has a few more side effects with it. So when we do the bone marrow aspirate concentrate, or BMAC as it’s easier called.
Carolyn: Oh that’s much much better.
Dr. Schafer: Much easier to refer to it as BMAC.
Dr. Schafer: So we’re able to take it out of somebody’s hip and give it right back to them.
Carolyn: That is so cool. Now, coincidentally, I was just talking to my sister, I believe about this therapy. She has torn her meniscus, had surgery and had the PRP, the platelet-rich-plasma treatment.
Dr. Schafer: Yes.
Carolyn: And that was pretty good, but is now considering the BMAC and I think it’s kind of one of those, maybe she should just stick with the PRP, or should she go with the BMAC? I mean, the PRP was successful for a time, but now she’s feeling the little aches and pains again in her knee.
Dr. Schafer: One of the big distinguishing factors is, what is the difference in platelet-rich plasma versus the BMAC therapy? So in platelet-rich plasma, we take blood from your arm, we spin it down and we can inject that back into injury, such as a meniscal tear, arthritis or tendon injuries. That is a very simple procedure with very few side effects. And what your own blood contains are platelets and other factors that have anti-inflammatory properties. So not only what we’re injecting back into you is anti-inflammatory in nature, but it also pulls cells from the rest of your body that are also anti-inflammatory.
Now, when we move to a treatment such as BMAC, which is a little more invasive of a therapy, since we’re getting the medicine from your hip, it also contains some of those similar cells as the platelet-rich plasma does, but it’s also known to contain some early signs of stem cells as well. So the goal with that is it might be able to help I’ll say regenerate, but regenerate to a limited factor, some cartilage or some meniscal cells to help aid in that healing process.
Chris: Now we’re talking about a scope of treatments known as orthobiologics, correct?
Dr. Schafer: Correct.
Chris: And that covers the platelet-rich plasma and it covers the bone marrow aspirate concentrate, or BMAC. Are there other things in that category?
Dr. Schafer: There are other things in that category. They’re not things that we’re currently offering here at UConn, as they are more investigational in use, such as the adipose tissue harvest that I previously mentioned such as amniotic cells, which can actually be purchased and then delivered to patient tissue as well. But that treatment in particular is what you usually first think of when you hear the term “stem cells” and that treatment has many more side effects, that just hasn’t been deemed to be safe yet. So that’s why we’re not offering it here at UConn at this time.
Carolyn: For the PRP or the BMAC, who are the best candidates for those therapies, would you say?
Dr. Schafer: Right now, what most of the research shows, and what we found clinically, is that active patients that are healthy tend to be the best patients for this. I don’t take age as a cutoff. I think age is more of a number. There are many 75-year-olds that are extremely healthy and extremely active that might be a great candidate for this in addition to those that are 18 or 30. I think being an active individual and taking that ownership in your health is very important for this, because with these therapies there is physical therapy and protocols afterwards as well.
Chris: What is the conversation with the patient go like when it comes to setting expectations and whether this may be an effective treatment for the individual?
Dr. Schafer: We want to know that you’ve tried some more conservative things first, maybe physical therapy, maybe a cortisone injection, if appropriate, and that maybe those haven’t gone to give you enough improvement in your pain as you would hope. Other than that, some of the screening is more for medical conditions or with certain medications that you might be on. Some patients are just not candidates for this. Other than that, the conversation usually goes about the procedure itself, and then the expectation that it could be one single injection to help you get the pain improvement that you want, but it might be repeated injections over the next couple of years.
Carolyn: So who wouldn’t be a good candidate with these therapies?
Dr. Schafer: Patients that are diabetics, patients on any blood thinners, because that is altering the composition of blood that you take, patients on certain rheumatologic drugs — right now, some physicians are doing the treatment and some aren’t, so we take that more on a case-by-case basis, ust because it does lower your immune system of little bit.
Chris: And due to the progress of this type of thing, specifically speaking about the BMAC now, the bone marrow aspirate concentrate, it’s not going to work for everybody, at least we’re not at the point now where we know definitively this is going to work for everybody. Why does it work for some and not others, and kind of speak to that variance a little bit?
Dr. Schafer: Absolutely. So I do think one of the things depends on the progression of your disease. If you have end-stage bone-on-bone, knee arthritis, you’re not going to be a good candidate for this. The improvement that you’re going to get as likely to be minimal versus somebody that might have earlier onset disease, or just maybe one patch of cartilage loss in their knee. At that point, it’s about preserving the patient’s knee and keeping them active as long as they can, until they might need a knee replacement down the road. For more of a tendon and ligament procedure, a lot of times it’s more about the chronicity of the disease. If you’ve had pain in say the tendon in your knee for 10 years, I would tell patients it’s unlikely that there’s much that you can do in one fell swoop that would take all of your pain away, versus somebody that’s only been dealing with it for my maybe a year might have a better response to initial treatment.
Carolyn: As far as side effects, it doesn’t seem like there’s like something horrendous that could happen to you with these injections.
Chris: Because it’s not a drug, right?
Dr. Schafer: No, it’s not a drug, we’re just taking your own components. The only thing that’s ever added to it is an anticoagulant so the blood doesn’t clot in our processing machine, and that’s processed out and not injected back into you. You are only receiving your same cells and it all happens in the same visit, so nothing’s being stored.
Carolyn: OK, so that being said, how about if, because I’m noticing a few tweaks in my knees after a workout on the treadmill, so what if I got these injections and it just helped prevent any future, more serious damage?
Dr. Schafer: I think that would be fantastic, and that’s one of the things that we are studying right now in the literature, especially with the BMAC is, can it help preserve cartilage loss? It’s something that I think about on a regular basis, would I just want to inject it into my knees that I’m sure are deteriorating by the year, just to see?
Carolyn: Â Because you used to play college basketball, right?
Dr. Schafer: Yes. I used to play college basketball. I am convinced there are many things wrong with my knees and ankles that I just don’t want to get looked at because I don’t want to know. But I do think, if this therapy becomes the therapy that I’m hoping it will, you know, could it help prevent me from needing a knee replacement one day? And that’s my hope for this field of orthobiologics in general.
Chris: As a former competitive athlete in high school and college, something like this, if that were available to you back then going through the rigors of the practice every day and all the competition, is that something that you think might’ve helped you back in the day?
Dr. Schafer: Absolutely, I definitely had some ankle injuries and some chronic knee pain throughout my time as a collegiate athlete. And I think having the option to try these would have been beneficial to me. I know certain athletes that I treat right now find it very beneficial, especially when we’re trying to decide, is there something we can do short of surgery? A big thing with an athlete or any active individual is keeping them in the game, keeping them in the gym. So if we can do something short of surgery to help with that, in my opinion, it’s, let’s give it a shot, no pun intended, and try it out.
Chris: Regarding, let’s say you were able to go back in time and administer this to yourself as a collegiate athlete, how long would you be out of action before you could start playing again? Because things got to get worse before they get better with this treatment, right?
Absolutely. So I usually have about a six-week protocol that I put patients through, and it does vary based on how involved of a procedure that we need to do. But in general, I like to shut people down for a couple of weeks, give the platelet-rich plasma or BMAC time to kind of set up, give their body some time to rest. And then with some of these conditions, we are trying to heal things more appropriately. So around week three, we’re doing some physical therapy and around week five, we’re starting to get back to more active things like maybe a light walk-to-run program. I’d probably keep somebody off the basketball court for at least six weeks after doing one of these.
Carolyn: But the appointment itself is just one time, as far as the taking from, for the BMAC, taking it from the hip and then injecting it, that’s all just one appointment?
Dr. Schafer: Absolutely, I usually see patients for a consultation first just to run through everything with them. And then when they’re scheduled for the actual procedure, that time will take about an hour or two, and it’s all start-to-finish taking the medicine out and putting it back in.
Carolyn: That’s amazing that it’s that quick. What about insurance? Does insurance cover it?
Dr. Schafer: Unfortunately, insurance does not cover this yet. Given that it is still investigational and we’re trying to figure out the nuances of the treatment, insurance does not have coverage for this yet.
Chris: How do patients find their way to you? Does someone need to refer to you, or can someone listening to this just call you up and try to get in to talk about this for a consult?
Dr. Schafer: Absolutely, I’m taking new patients and I see new patients in my practice every day. So I’m happy to see patients of all activity levels if they’re interested in this and interested in taking control of their injury and trying something new for it.
Carolyn: That’s great.
Chris: Do you think there’s enough awareness out there in the referring physician community, maybe primary care docs and maybe other sports medicine folks, are enough of them aware that this could be an option that their patients might find out through their own provider to find their way to you?
Dr. Schafer: I don’t think so. I think we’re still very specialized in a field of this. So I think a surgeon and a non-operative sports medicine physician are going to know some about it. I think some primary care docs will because there is more and more literature out about it these days. But unfortunately, there are also a lot of misconceptions about this therapy out these days.
Carolyn: Why is that?
Dr. Schafer: Well, I think the word “stem cell” is always surrounded by some controversy and I think, although it’s still investigational, we know some patients it works well for, some patients it doesn’t work well for. But I think there’s often a little bit of an overpromise for what this can do, knowing that we need to take the whole patient’s circumstance into account for this. So I think there’s a lot of misinformation out there and a need for more information in our community docs.
Carolyn: And I would think you would want to avoid surgery at all costs, so it seems like at least something to try it’s worth examining.
Dr. Schafer: Absolutely, and you know, some injuries need surgery, maybe a torn ACL and a young athlete or a traumatic, full thickness rotator cuff tear, none of these therapies are going to regrow your entire rotator cuff and get you back to the function you want. But one thing we do find is for the patients that are stuck at an in-between, where surgery is not a clear-cut home run for them, that this is a great option to try. And if it works fantastic, you have not had to have surgery, and if it doesn’t, maybe surgery’s then a true last and final option.
Chris: It’s unlikely to make it worse.
Dr. Schafer: Absolutely, we haven’t found very many side effects for this therapy. For example, cortisone injections, if you get repeat injections into your tendons, can cause little calcifications and things of that nature. We haven’t found that PRP does that.
Chris: Dr. Allison Schafer, before we let you go, can you give us a little bit of a sense of kind of where we are with modern medicine is in terms of accepting this? You mentioned insurance isn’t really quite on board with it, we’re still kind of considering this investigational, I mean, has there been advances in kind of general acceptance of ortho biologics, such as BMAC?
Dr. Schafer: I think there has to an extent. As I spoke on briefly earlier, there are other types of stem cells that can be purchased from, say, amniotic stem cells and some of the other type of stem-cell therapies out there for other medical conditions in general start off with a very early stem cell that can turn into possibly anything in your body. More of what we’re trying to do our research on right now in my particular field are the stem cells that we know can only turn into what you put them near. So if we put it into your knee, we know it’s not going to turn into a tooth. So I think in the realm of that kind of stem-cell therapy, there is a much greater acceptance of it. If you take the word stem-cell therapy as a whole, there is still quite a bit of controversy surrounding that.
Chris: Well, hopefully discussions like this can maybe spread some awareness about that and help this concept advance even further and help more people.
Dr. Schafer: I hope so. I think the more people that we have to try this, the more data we get, which is important, the further this field is going to continue to advance over the next five years.
Chris: And that’s our time for today. For Carolyn Pennington and Dr. Allison Schafer from the UConn Musculoskeletal Institute, I’m Chris DeFrancesco. Thank you for listening to the UConn Health Pulse. Now be sure to subscribe, so you can catch us next time, and be sure to tell a friend.