ARTHRITIS REGENERATIVE MEDICINE ORTHOBIOLOGICS AND PRP

Arthritis, Regnerative Medicine, Orthobiologics, PRP & Stem Cell Therapy

Arthritis is a general term which implies inflammation of a joint. There are many forms of arthritis.

Osteoarthritis is the most common of many forms of arthritis which can affect people. In general when people say they have arthritis they usually imply osteoarthritis. It is estimated that 50% of people over 50 years of age have osteoarthritis. Although common and a potential source of pain and reduced function there is a lot one can do about arthritis to relieve pain and maintain or improve function. 
Arthritis is felt as joint pain, stiffness, swelling and restricted movement and function. Much of this reduced function is as a result of soft tissue changes around the joint and the limb in general and not only joint breakdown. This can be as a result of tightening of the tissues after cycles of inflammation or irritation as well as weakening and lack of coordination of the supporting muscles. This is one of the reasons that a patient can have significant pain yet minimal changes on imaging such as X-ray or MRI. On the other hand, some patients can have significant changes on imaging with minimal or no pain. The most common factor in these patients is the optimized state of their soft tissues. The soft tissues are addressed using appropriate rehabilitation to optimize alignment, coordination, flexibility, and strength. Lack of soft tissue support can lead to unnecessary accelerated joint breakdown.

The other factor causing pain and disability in arthritis is cartilage breakdown and joint remodelling. Left on its own, osteoarthritis generally progresses over time and is responsible for a significant cause of disability as a person ages. 

Although we do not know the exact mechanisms involved in the onset and progression of arthritis, the process in part involves cartilage breakdown. Underlying factors usually include genetics, previous trauma – acute or repetitive, previous infection or significant anatomic variations in alignment and biomechanics. As part of the process there is breakdown of the molecular scaffold which makes up the cartilage lining of the joint structures. This scaffold breakdown allows the water normally trapped within the scaffold to be released changing the properties of the cartilage. This results in decreased shock absorption through the joint and increased friction during normal joint movement. This in turn leads to further breakdown of the cartilage and a vicious cycle of cartilage degradation in osteoarthritis. Once the cartilage starts to break down, excessive forces are transmitted to the bone surfaces which are usually protected by the cartilage. This leads to characteristic changes in the bone which lead to joint deformation and dysfunction including pain, swelling and restricted range of motion. The pain and stiffness lead to decreased use of the joint resulting in a weakening of the surrounding muscles. Muscles which act on a joint not only move the joint but provide it with appropriate support and shock absorption. With decreased use of the joint, the affected muscles lose this ability resulting in a loss of joint protection and further joint breakdown.
Arthritis is diagnosed on clinical grounds through a medical history and physical examination. The diagnosis is supported or confirmed by investigations including x-rays, bone scans, CT, and MRI. All joints in the body can be affected, however the most common joints include the spine the knees, hips, feet, and the shoulders. The most common joints that are replaced surgically include the knees and hips. Surgery is available for other joints such including the spine in selected cases.

Currently there is no known way of fully reversing arthritis once it starts. The treatment of arthritis involves providing biomechanical support (braces, orthotics, rehabilitation) and chemical support (hyaluronic acid, PRP, stem cells) support to the joints involved and treating the pain stiffness and swelling, as necessary. The goal is to maintain function and slow down the further breakdown of the arthritic joint. This may delay or completely eliminate the need for surgery including joint replacement.
The most important factor in treating arthritis is trying to maintain adequate biomechanical support and stability for the joint while providing relative rest of the joint. The team at our Toronto sports medicine clinic achieves this through a comprehensive program of flexibility and strengthening provided through physical rehabilitation. Specialized rehabilitation techniques such as aquatic therapy, available at The Toronto Centre for Sports Medicine provide a unique and unmatched method of rehabilitation of osteoarthritic joints. Further support of the affected joint can be achieved with specialized bracing and orthotics and orthobiolgics such as viscosupplementation and PRP.

Chemical support of the joint can be achieved through various means. Oral intake of glucosamine and chondroitin (two of the molecular building blocks of the cartilage scaffold) are available as over the counter supplements in pharmacies and health food stores. While there is controversy as to whether they glucosamine and chondroitin are effective, many studies backed by clinical experience seem to indicate that they can help relieve inflammation and pain and may help to slow the progression of osteoarthritis. It is too early to say whether these products can reverse the arthritic process to any degree. The good news is that they have very few side effects and are fairly inexpensive. These supplements are generally contraindicated in diabetics or people on anticoagulants.

Viscosupplementation is the injection of hyaluronic acid (another molecular building block of the cartilage scaffold) into a joint. It has been found to relieve inflammation and pain and preserve joint function. There are many products available on the market, often covered by extended health plans. These products are injected during a short office procedure which is no more painful than receiving an immunization or blood test. The effect of these injections may last up to six months at which time they can be repeated. Patients with moderate arthritis have obtained significant relief and attained increased function of the injected joints. The most common joint injected is the knee.


One of the products we have injected extensively at our sports clinic in Toronto is Durolane  We are very excited about such products because the ease of administration (only one injection), the low rate of side effects and the excellent functional results patients have obtained. Viscosupplementation should be considered in anyone with mild to moderate osteoarthritis especially of the knee.


PRP  or platelet rich plasma is a technique that involves drawing a small amount of a patient’s blood and then isolating platelet growth factors found in the blood by centrifuging the sample. The isolated growth factors are then injected into the affected arthritic joint. These growth factors are thought to stimulate cartilage cells to produce more cartilage. 


PRP has been around for at least 30 years however only in the last 10 years have we seen substantial and consistent scientific evidence that PRP does make a difference in relieving pain and improving function in arthritic joints. Due to the mechanism of action, PRP is felt to help to restore the cartilage of an arthritic joint. There are several protocols used in PRP treatment of arthritic joints which depend on individual patient factors. These details are determined after an appropriate medical assessment. 


At the Toronto Centre for Sports Medicine we use the Harvest Smart Prep system for our platelet rich plasma treatments providing one of the highest concentration of platelet growth factors in the resulting PRP distillate. In addition, we go one step further and make use of The Harvest Terumo Clear Prep system which further separates out white cells from the growth factors in the platelet rich plasma. White cells are thought to increase the chances of pain and inflammation after PRP injections into joints. 


nStride APS or Autologous Protein  Solution by Zimmer Biomet is a technique similar to PRP with the added process of removing any inflammatory factors from the blood and concentrating the anti-inflammatory factors to results lasting 1-3 years in arthritic joints.


Stem cells is another technique in which stem cells harvested from the patient are isolated by centrifuge and then injected into the arthritic joint. This technique is thought to stimulate the generation of cartilage cells which will then produce cartilage. At the present time there is a moratorium on stem cell treatment in Canada until Health Canada determines its safety and guidelines for use. We are closely monitoring the status of stem cell therapy in Canada and will be here to provide you with appropriate stem cell therapy when it becomes available.

With regards to orthobiologics including viscosupplementation and PRP listed above, the earlier the interventions are instituted the more effective they will be in providing pain relief, joint preservation and joint function. The most efficient and effective program of regenerative medicine combines interventions of orthobiologics and comprehensive physiotherapy. 

In summary arthritis is quite common in our population. Treatment is changing rapidly for the better. There are many options available for patients to reduce pain retain function and avoid surgery. Please book an appointment at The Toronto centre for sports Medicine to assess your needs and provide you with a customized plan to treat your arthritis and optimize your functioning. 

Treatment of arthritis through physiotherapy viscosupplementation and PRP is available at the Toronto sports medicine clinic. 

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