In this post, IBJI’s Dr. Eric Chehab discusses the topic of stem cell therapy for patients living with knee pain. Dr. Chehab sees tremendous potential in this therapy, but suggests that patients “proceed with caution” based on the current scientific research.

This is the first in IBJI’s “Perspectives on emerging treatments and therapies” blog series. IBJI is committed to educating patients about emerging treatments and techniques, while ensuring that they understand the pros and cons of these procedures and approaches. This knowledge is especially important in cases where the science remains inconclusive.

Stem cell therapy for osteoarthritis – a word of caution

By Eric L. Chehab, MD

I get the question nearly every day from patients seeking pain relief from their knee arthritis. “Doc, what about stem cells?” And I initially hesitate…

Stem cell therapy – the use of primitive cells that can differentiate into multiple types of cells- provides promise for the treatment of osteoarthritis. The loss of cartilage in a joint – along with the loss of the cells that produce and maintain cartilage – is the single common pathway to the pain, swelling and dysfunction that accompanies osteoarthritis. Stem cell therapy aims to replenish those lost cartilage cells. Those replacement stem cells can then produce the cartilage that has been lost. This is truly one of the holy grails sought in orthopedics. It’s this intuitive appeal that leads to so many inquiries regarding stem cells.

I see hundreds of patients a month with knee pain and arthritis, and though we orthopedists have several effective pain relieving, symptom-modifying treatments, we currently have no FDA approved treatments that reverse the disease course of arthritis. We use NSAIDs, physical therapy, weight management, cortisone injections, hyaluronic acid injections as non-invasive treatment modalities. But these are symptom modifying treatment, not disease modifying. Even knee replacement, which is the ultimate end line treatment for arthritis, is considered a symptomatic treatment. In essence, all our current treatments can be considered band-aids. Stem cells, however, have the potential to address the root of the problem …. The loss of cartilage cells. Stem cells would therefore be a disease modifying treatment.

So why my initial hesitation? First and foremost, there is currently a lack of good evidence that supports its use. Though there have been several published studies suggesting that stem cells are effective treatments, these studies lack controls, which makes it impossible to determine if the effect is simply placebo. And from the few studies that have used controls, the effect is currently modest at best – and still may be due to placebo.

In addition, many patients are asking about stem cells in response to direct-to-consumer advertisements by clinics and physicians that espouse the utility and efficacy of stem cells. In my heart of hearts, I can’t help but feel that these clinics may be taking advantage of a vulnerable population in whom treatment options are limited. To top it off, many of these clinics charge several thousands of dollars for the treatment, which is not covered by insurance.

So on the one hand, there’s promise for a condition where we have limited treatment options. On the other hand, there’s a lack of solid evidence, and there’s tremendous expense. Hence my hesitation.

So the best advice I can give to patients who wish to pursue stem cells is to proceed with caution. I would recommend starting with standard symptomatic treatments as outlined above, as many are effective, relieve pain, and improve function. If, however, these fail, then it’s not unreasonable to consider stem cells. I would recommend seeking a center that is enrolling patients in a clinical trial, or is standardizing their practice across a large number of patients. With standardized treatment, we orthopedists can effectively compare the outcomes of stem cell treatments. One of our current limitations is that there is a huge diversity of cell preparations and delivery methods, which makes studying outcomes and efficacy much more difficult. And if you choose to pursue stem cell therapy, be prepared to pay. It can be a considerable out of pocket expense, for something that may or may not work, and may have a modest benefit at best. However, if you have the means, and have tried other methods that have been unsuccessful, it may be worth a try.

It is my hope that with time, we can perfect cell delivery and incorporation, and provide patients with a viable replacement for lost cartilage. That would be a huge advance in the field of orthopedics – a holy grail. And our current stem cell work is very likely a step in that direction…. But please understand there is still a long way to go.

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