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7/14/20

Platelet-Rich Plasma (PrP) vs. Stem Cells vs. Exosomes

We read almost weekly articles in the popular press about regenerative medicine, extolling the virtues (or the follies) of strange-sounding treatments: platelet-rich plasma (PrP), mesenchymal stem cells (whether bone marrow or adipose tissue-derived), amniotic fluid, umbilical cord blood, placenta, or, stranger still, exosomes.

Your confusion about all these treatments is understandable. Don’t feel bad! A lot of physicians out there don’t know this terminology either.

This blog will not rehash things we have written about extensively already. For example, you can go HERE for information on platelet-rich plasma, or HERE, HERE, HERE, and HERE for information about stem cell treatments for neck pain, shoulder pain, knee pain, or back pain, respectively.

Rather, this blog will aim to help you understand our thought process behind choosing the appropriate treatment for your condition. We will explain why we do things the way we do them.

Step 1, as always, is to decide whether somebody is even a candidate for regenerative treatments. Judging by some of the social media ads out there, one would think that the only criterion for these treatments is having a pulse (!). The truth is obviously more nuanced than that. This decision rests on a very simple observation: how bad is the injury or how advanced is the degeneration? Luckily, we are able to perform a full analysis, based on chronicity, sophisticated scans, and history of other treatments.

If the injury or the degenerative process are not not bad enough to warrant surgery, then we can move on to step 2. Now, this is a very important decision: do not delay a surgical intervention and do not set up false expectations. It is worth mentioning that most regenerative treatments are not backed by strong research.

Step 2 - once the decision was made to pursue a regenerative program, we ask ourselves whether you the patient are in an optimal state of health to respond to our treatment. This is where our Functional or Integrative Medicine approach stands out from the crowd. Our blood biomarker analysis will evaluate your inflammation, your auto-immunity, and your metabolism. By optimizing your health, we will prepare the soil to receive the regenerative seeds.

Step 3 is actually what this blog is about. How do we choose which regenerative cells to use? The two guiding principles here take into account the age and health of the patient and the severity of injury.

As far as we can, our preference is to always use our patient’s own tissues, blood for PrP, bone marrow or adipose tissue for stem cells. This allows us to control the whole process: extraction, separation/concentration and delivery. We also have a thorough quality analysis process (cell counts, flow cytometry for viability and determination of type of cells, and incubation for subsequent microscopic counting of fibroblast colony forming units). We have information about the quantity and quality of the cells we use and we correlate these with the clinical results.

For peripheral mild to moderate tendon injuries (partial shoulder rotator cuff tears, shoulder labral tears, tennis/golfer’s elbow, carpal tunnel syndrome, mild hip osteoarthritis, hip labral tears, gluteal or hamstring tears, trochanteric bursitis, mild knee osteoarthritis, mild meniscal tears, ankle ligament sprain, plantar fasciitis and others), platelet-rich plasma is usually a good alternative of treatment. The ease of collection and lower cost are advantages. The need for repeated treatments is somewhat of a disadvantage.

If the injuries or osteoarthritis are severe, then stem cells are a better alternative. One advantage of stem cells are the fewer treatments, and potential drawbacks are the cost and the somewhat more difficult collection from bone marrow or adipose tissue.

Some of you probably noticed I have not mentioned the spine. It is because spine problems are always more complex and the algorithm of treatment is too complex for the purposes of this blog. We have written about neck and back pain before and how stem cells can help.

The age of the patient determines whether patient’s own stem cells are used or not. After age 45, the number of stem cells in bone marrow decreases rapidly every year, although paradoxically this decline is not seen in the adipose tissue stem cells. The general health of the patient also contributes to the number and quality of stem cells in their tissues.

For a patient who is 50 years old or older, while we can still use PrP, we have to make a decision on whether we use their tissues for sources of stem cells or we resort to commercially available regenerative cells derived from healthy donors.

There is a plethora of these commercially available products, ranging from growth factors derived from placental tissues (umbilical cord blood, amniotic fluid, Wharton’s jelly, etc) to small cells derived from donor stem cells. These small cells (nanoparticles) are called exosomes, and they are the result of a purification process of stem cells. The result is a concentration of proteins, messenger RNA (mRNA) and growth factors, without any of the original cell’s DNA. The lack of DNA makes rejection of these cells impossible so it lowers the risk of their use.

We have used all these commercially available products throughout the years and, at this time, we decided to use exosomes derived from bone marrow of healthy donors. This decision is based on our own experience and FDA decisions on whether these products are what they claim to be.

Therefore, for an older patient in whom we treat moderate osteoarthritis, we usually use a combination of patient’s own PrP and commercially available bone marrow derived exosomes.

It is beyond the scope of this writing to describe exactly which treatment applies for which condition. We merely want to explain that each patient is treated like an individual, which is the definition of Precision Medicine or N=1 Medicine. The choice of regenerative cells is highly individualized based on our experience, age and health of the patient and the extent of injury or degeneration. Our regenerative plans of treatments also employ several other helpful strategies. Peptides, supplements, fasting and direct current-enhanced exercise therapy are just some of them.

Ultimately, nothing can substitute a thorough evaluation, history, physical examination, review of radiology, and a diagnostic work-up. We hope that you keep these things in mind when you seek regenerative treatments anywhere.

We are available for consultations and to explain these principles further. Please contact us with any further questions!

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