Dr James Leiber Facebook Live Q&A | Cartilage Deterioration
Regenexx Cayman visiting physician, Dr. James Leiber from Regenexx Tampa Bay, recently participated in a Facebook Live. During the Q&A, Dr. Leiber answered patients’ frequently asked questions about cartilage deterioration. You can watch his Q&A session in full below. And if you still have questions please don’t hesitate to contact the Regenexx Cayman patient care team directly.
Don’t forget to download our FREE booklet about the top 10 causes of cartilage deterioration to see what you can do to prevent and avoid cartilage loss
These are just some of the questions that Dr. Leiber answers in the video.
Regenexx Cayman: Hi everyone, thanks for joining us today. My name is Emma and I’m a marketing supervisor here at Regenexx Cayman and I’m pleased to welcome our visiting physician from Regenexx Tampa Bay, Dr. James Leiber, so thank you for taking time out of your schedule today.
Dr. James Leiber: Thank you, my pleasure.
RC: And so today Dr. Leiber is going be answering some of your most frequently asked questions about cartilage loss and deterioration, so feel free if you have any questions to drop those in the comments and we will try to get back to you live. Plus we’ll also leave in the comments a free link to our 10 Top Causes of Cartilage Deterioration so you could download that free booklet if that’s of interest.
So for those of you who don’t already know very much about Regenexx Cayman, we are an orthopedic stem cell clinic right here in Cayman – in Grand Cayman, sorry, and we offer both blood platelet and stem cell procedures including; Regenexx-C which is the most advanced orthopedic stem cell procedure in the world, and the blood platelet and stem cell procedures, are a great non-surgical alternative for people with joint issues injuries or conditions, so for example, degenerative disc disease, ACL and meniscus tears, golfer’s elbow, tennis elbow, arthritis – and there’s a full list of conditions if you’re interested on our website regenexxcayman.ky. So, let’s just to allow a few more people to tune in… Dr. Leiber, perhaps you’d like to tell us a little bit about yourself and how you came to work in the regenerative medicine field.
JL: My name is James Leiber, I’m a physician licensed in the United States in Florida, I have two offices there, one in Tampa and one in Sarasota Florida, and I’m also licensed down here in Cayman and I come here approximately one time a month to see patients down here, often seeing the patients that I was seeing in Florida. So I’ve been part of the Regenexx affiliate network for quite some time now, at least seven years, and I’ve been doing regenerative medicine – that is injections of stem cells and platelets, trying to strengthen tissue and we’ll get more into that in just a moment. Going on probably somewhere between 10 to 12 years. And that was a long, you know, evolution to get to that point.
I have been involved in the Air Force for 11 years, and I practiced primary care medicine initially, but then I was involved with pain medicine, and it was just a natural evolution – getting expert in use of ultrasound to visualize orthopedic tissue. Once you can see it real-time then you now can get a needle to it real-time and why would we put anything into that tissue other than something that can strengthen it? And so it was just an evolution to get to that, and then I joined Regenexx knowing that they were by far the most organized and research-based organization and it’s been a great relationship ever since.
RC: Well we’re definitely glad to have you here at Regenexx Cayman.
JL: Thank you.
RC: So briefly perhaps you can talk us through, for the people that are coming to listen about cartilage deterioration, – a bit of cartilage 101. What is it, where is it in the body, and what is its function?
JL: Okay so most people have heard of the term cartilage at some point, cartilage exists in joints, knee joints, hip joints, shoulders, and fingers. All these joints are in the lining of the bone within the joints, so the joint is where two bones come together, and the lining on top of the bone is cartilage – we call it hyaline cartilage, it’s a specific type of cartilage. It’s avascular – meaning it doesn’t really have any blood supply and it also doesn’t have any nerve endings associated with it, so you don’t really feel pain from lack of cartilage or wear of cartilage. Mainly we think of it as a shock absorber for the joint, and so I think that’s basically the 101 version.
RC: And what is it that causes cartilage to deteriorate?
JL: So cartilage can deteriorate from a number of different things. There can be trauma – any kind of injury, an impact to the to the tissue that causes a little bit of damage and that can accelerate over time. It can be from typical wear and tear of life, and overuse and repetitive use, but there’s also a lot of metabolic or internal chemical factors that influence that, their genetics [might] play a role, what we eat, exercise, our levels of intake of certain types of foods can potentially impact that. How we manage our pain also has a big influence, in other words if you take anti-inflammatory drugs to manage pain in various places that can actually accelerate the cartilage deterioration. If you happen to get cortisone placed into the joint that’s also going to accelerate the cartilage degeneration, and then even surgery which can be beneficial for some things can actually accelerate the cartilage wear as a side effect of that over time, so there’s a variety of different things that play into wear and tear at the cartilage
RC: I suppose it’s interesting just then that you mentioned pain and how cartilage isn’t causing that pain. I suppose you get a lot of people that come in and say “oh well I have cartilage loss and I have pain from it”. What is it that’s causing that pain if it’s not the cartilage…
JL: Yeah that’s a great question – comes up almost every appointment. People say, “my Doctor told me, “here’s my MRI – I don’t have any cartilage” and can you regrow the cartilage, and is that going to solve my problem?” Again, so cartilage has no nerve endings – you don’t really feel pain from lack of cartilage. Cartilage basically is our visual evidence that there is disease in the joint, it’s the victim of the arthritic process. So, arthritic disease, arthritis – there are chemicals in the joint that are out of balance, there are more chemicals that are trying to destroy tissue than there are chemicals that are trying to repair tissue. And as that balance is in the favour of the destruction of tissue, cartilage is a victim of that, and it starts to wear away, and then when we look on an x-ray or an MRI, we see evidence [that] arthritis is there because the cartilage is wearing away. But the pain source is not really the cartilage, or the lack of cartilage.
We think there are various different things that can cause pain in the knee. We know that the lining of the joints – there’s a lining called the synovial lining and that synovial lining produces a normal healthy lubricant for the joint as nutrition, but in the arthritic disease, the synovial lining becomes lumpy bumpy and can start producing inflammatory destructive chemicals. And that lining is filled with nerve endings, so we know that that lining is a source of pain for people.
The bone that lies underneath the cartilage, that’s called a subchondral bone. That is very can be very sensitive, and that could be a source of pain for people. And then at times if you have an injury to a meniscus, or a ligament, or tendon and certainly that could be the source of pain. So we’re trying to address all those different factors with our procedures. We’re not really just sticking some material into a joint, thinking we’re going to grow cartilage and solve everybody’s problem.
You can have no cartilage at all, and be extremely functional; an example I usually give is one patient, a sixty-year-old woman, who had seen me wanting to do an Ironman Triathlon. She was kind of a weekend athlete, and so I said I’m not sure you can do this triathlon anyway, but let’s take a look at your knee and see what’s going on – and she had no cartilage on the inside of her knee. I told her that we can probably create stability in the knee, decrease the inflammation in the knee, strengthen the meniscus tissue in the knee, and maybe you improve the health of the remaining cartilage. And we did that procedure and she trained then for 9 months and then completed the Ironman. Again with no cartilage on the inside of the knee, so it just shows it can be extremely functional and have little to no pain even without cartilage.
RC: So you touched there on arthritis and cartilage loss. You were saying that you can function quite well without any cartilage, but are arthritis and cartilage loss always hand-in-hand or can you have healthy cartilage and have arthritis?
JL: Well it’s how we grade arthritis so you know when we look for visual evidence of arthritis, we would make a diagnosis, it’s not a biopsy or a laboratory test, it’s a visual diagnosis. So we look at for example the most common ways is an x-ray and you look, let’s use a knee as an example, on the x-ray we’re going to see joint space that is narrow – that’s part of the diagnostic criteria. That’s probably at least in part because of cartilage is wearing away.
We see changes in the bone underneath the cartilage, that’s also part of the diagnostic criteria, and then we see bone spurs. And bone spurs are not something in isolation, that’s part of the arthritic process. And so yes, if you have arthritis you are going to have visual evidence of cartilage wear. The worst wear is, then we would grade the arthritis.
RC: And can cartilage deterioration affect every joint? I know there are different types of cartilage all over the body, and different thicknesses, but are they all affected in the same way?
JL: You know, we have some joints are weight-bearing joints and other joints are like fingers have a lot of use associated with them, but the arthritic disease looks the same when we look at it on the imaging and any joint that has synovial lining is subject to potentially having arthritis.
RC: You also mentioned before about patients come to you and they expect to regrow or regenerate cartilage, and I know this is probably the top of everyone’s mind in terms of questions – is it the case that you can regrow or regenerate new cartilage with stem cells, or can you repair damaged cartilage with stem cells?
JL: So you know, there are times that we can see little slivers of cartilage regrow, especially if you get specialized MRIs and types of software to look at that, but in general we’re not really seeing and once the cartilage has really worn away, we’re not really seeing growth of that cartilage. But we also are not seeing that correlate in any way to somebody’s results, so you cannot grow cartilage, which is typical, and have phenomenal clinical results – in terms of pain and function. And so at this point in time the technology the way it exists today in the world, we’re not really seeing a consistent growth of cartilage. There are times where we can see small amounts, but it’s very inconsistent and again unrelated to somebody’s outcomes.
RC: So then how is it that Regenexx stem cell and blood platelet treatments can help people that are suffering from things like arthritis or you know this cartilage loss that they feel is causing them pain, how is it that we can help them?
JL: So it’s a matter of addressing the issues that are causing the pain and creating an environment that’s unhealthy in the joints. So I think the stem cells and the platelets, their main role in the joint in which there’s a lot of cartilage loss is first of all, decrease the inflammation and change the way the synovial lining that’s producing this inflammatory fluid – kind of reprogram that lining in a sense so that starts producing more healthy fluid, so this less of a more balance of cells trying to repair than destroy actually favoring repair, that changes the sensation of pain in that lining.
If there are issues with the bone underneath the cartilage, then we can inject directly into that bone and that will help with the pain associated with that. And a matter of fact, the bone underneath the cartilage, when that’s swollen we’ll call it bone edema or bone marrow lesions – those are associated with pain on research studies much more so than the loss of cartilage or meniscus tears. That is really often the source of pain.
And then if the meniscus is weakened, we can likely strengthen that and then a lot of it has to do with the stability of the joint. So there may be some slight laxity that is the ligaments that hold bone-to-bone together, may be a little bit loose or even torn, and we can get those to strengthen so that the stability in that structure is better. So once you have stability you have less wear and tear on a joint. Instability creates a lot of shearing forces on the cartilage, on the meniscus, that can be, and then on the synovial lining that can be a source of pain. So we’re kind of treating the whole structure trying to get that whole structure stable, less inflamed, healthier, in its environment basically.
RC: Is there a particular difference between treating these symptoms with the blood platelet treatments and stem cell treatments? Like, why would you choose one over the other?
JL: So blood platelets and stem cells basically work along the same spectrum. Once you have an injury or a cut or anything like that, you can imagine platelets kind of rush into the area forming a clot. Once that clot is formed and they open up and they spill out growth factors and these growth factors then work straight and stimulate the rest of the healing process, and one of the growth factors, in particular, will call stem cells to the area to recruit them to help with the repair. And part of that is maybe they may morph into the tissue that they’re trying to repair and in other ways if they’re going to secrete these other substances that will also help to orchestrate and complete the repair process so they’re all kind of working together in terms of the clinical.
Clinically we find that platelets are not as powerful as stem cells in terms of treatment and we’ll use platelets in milder to moderate conditions and then recommend stem cells which we use in combination with platelets for more moderate to severe conditions
RC: I suppose that’s why Regenexx-C, the exclusive procedure that we offer here, is particularly good in terms of severe cases?
JL: Right so Regenexx-C is unique in the world in that we’re able to… the laboratory here take the stem cells, isolate them, grow them into large quantities, really about a hundred to a thousand times more than what the baseline number is when we get them out of the bone marrow. And that pure line of large amounts of stem cells makes it a more powerful procedure, in general, we can treat more body areas, and in fact they can store the cells here for future use as well, and the storage is nice because it’s stored at your current age so if you’re 45, you can store them at 45 and use them when you’re 50 or 60, and you’re using the younger version of your own stem cells.
RC: Especially if there are aches and pains start to kick in I think they’re a very valuable asset to have.
JL: Yeah I think that’s one of the biggest benefits of this procedure.
RC: Side-tracking a little bit – do you think there’s a difference in the way the interventional orthopedics physicians view cartilage in comparison to other medical specialties. In terms of what they can promise, and what they see being done?
JL: Well I think, you know, if you’re talking about a standard medical approach to someone who has arthritis, we can talk about a knee or hip for example, or shoulder, it’s limited in what’s able to be done. I mean it’s usually going to be management of pain in some form or other. Cortisone injections, narcotics, anti-inflammatory medications, and in worse situations, then replacement of that joint. So they’re not viewing cartilage or the joint as something that can be preserved and improved and you know what are trying to do is a complete tissue preservation strategy.
We’re trying to strengthen the tissue, decrease inflammation, whereas standardly outside of our medical specialty it’s more management of pain, perhaps physical therapy, things like that. But that has a role to play, and we use that as well with our treatments, but nobody is really looking to grow cartilage right now. Nobody is able to really do that at a large level. And I’m not really sure that makes that much of a difference.
There are cartilage transplant procedures that orthopedists do, where they take cartilage from a non-weight-bearing portion of the joint and then they can grow it and then put it back into an area that’s lost the cartilage. And that can have some value in terms of the actual structural cushioning that the cartilage does but it doesn’t do anything for the health of the joint or the other structures that we talked about. So I think what we’re doing is a more complete treatment of that joint.
RC: And you’ve mentioned pain medication a few times now, and how actually that can have a detrimental effect on cartilage. So people that are in pain are taking things like the NSAIDs [non-steroidal anti-inflammatory drugs] or cortisone shots, you’re saying they can have a damaging effect on cartilage?
JL: People are either going to be into narcotics, these NSAIDs like ibuprofen, motrin for example, Celebrex these kinds of things or get cortisone injections. Narcotics we haven’t been able to identify something that damages cartilage, but there are obviously a lot of other issues associated with being on that kind of medication. Cortisone injections are very very powerful at degenerating tissue, probably the most powerful substance we know of to do that. And placing that into a structure that’s already very degenerated, there’s data now to show that it definitely will accelerate cartilage loss it’s not a good strategy and it has other systemic effects that I can talk about for quite some time.
And then the NSAIDs, the motrin, ibuprofen, those kinds of medications which are sold over the counter so people assume that they’re automatically a safe option – there are many many problems within us. We’ll get to the cartilage in a second, but they highly increase the risk of gastrointestinal bleeds which a lot of people die from throughout the world. It increases the risk of kidney failure, heart attack, and strokes, and not it’s not a minimal risk, it’s a pretty substantial risk. So we’d like to get people off of those medications if we can, but in terms of taking the medication on a regular basis – it’s been shown to approximately double the wear of the cartilage loss.
You know, people who are obese for example will also… for every pound basically of weight you gain you’re putting anywhere from two to four pounds or more of pressure on the knees. So a simple 10 pound.. well let’s do it the other way. A 10-pound weight loss you’ll be taking 20 to 40 pounds of pressure off of the knee. So now, let’s say you’re obese and you’re taking NSAIDs at the same time, then you double the actual wear potential of that cartilage over time. So helping people with weight loss, getting people off of these medications, giving them alternatives – an alternative strategy that is really an effective strategy and a safe strategy I think is, you know, why I love doing this.
RC: That’s our ultimate goal here as well is to hit the pain where it’s being caused, rather than just the symptoms and to mask those symptoms, which I feel is often what those medications can do.
JL: I mean they were used with good intent for many many years. The idea that inflammation is bad for a structure, therefore we give a strong anti-inflammatory like NSAID or cortisone, and we’re probably doing something good for the joint. But as time went on and as research has progressed, we know that that’s not the case. We really should be minimizing the use of these medications at this point with the knowledge that’s available in science.
RC: So how is it that someone can prevent or avoid cartilage deterioration?
JL: So I think we started to touch on some of these things. We talked about obesity and weight loss. Part of it is the weight, and part of it is the fact that fat cells can produce various types of substances, hormones, that have a negative effect on cartilage. Things like leptin, which is produced by the fat cells, can actually accelerate cartilage wear. So weight loss is important, but it’s not just about the weight.
It’s also about the type of food that we’re eating. Certain types of foods are more inflammatory or more oxidative and so we want to promote this type of a food plan in which someone is fairly low glycemic, in other words, they don’t get insulin spikes, so they minimize any added sugars and grains keeping those to a minimum, and any grains should be whole grains. Lots and lots of fruits and vegetables, there are some varying opinions about meat sources or protein sources. I favor more of a plant-based protein for the most part so I think those are things that can be done, someone can implement on their own.
There are certain supplements that we think may help protect cartilage, you know, there are certain scenarios like if you had trauma to the knee – there’s some research to show if you were to take a medication a supplement called n-acetylcysteine which is commonly used in the hospitals for people who have Tylenol overdose, it actually would protect the cartilage for that time that you’ve got the injury. So there are certain things you can do like. And then there’s having someone assess the stability of that knee you may or may not have any ligament tears, which may have some ligaments that are loose. And if they’re loose and there’s too much play that’s happening in the joint, that’s something that we can help with because you can’t really rehabilitate a ligament. You need to have it injected with some material to strengthen that tissue.
So I think that those are some things that we can do on our own maintaining strong, healthy musculature in the lower extremity, strong core. Also just exercising on a very regular basis, keeps our healing capacity at the highest level, keeps our stem cells healthy. And so we want to make sure we have aerobic and strengthening and flexibility training, maybe working with a therapist to make sure our biomechanics are symmetric. So those are some of the things I think that someone could do on their own.
RC: And my last question is, for anyone that is worried about that cartilage specifically, what are some of the early signs of cartilage loss that people can look out for or how can it be diagnosed correctly? You said it was quite a visual identifier.
JL: I mean some structures and some people don’t feel arthritic disease or pain, even until the cartilage is completely worn away. We see people like that all the time. They come in with hip pain, and it is the first time they have had hip pain ever. And you get an x-ray and they have no visual evidence of very very severe arthritis. It’s nice to catch it early but there’s not always a warning sign for a person to identify that it’s there. And it’s a little bit of a challenge to catch it early unless we do screenings of people which is really not commonly done. So if you’re having something you know that’s bothering you just get it checked out early rather than late, so that something could be identified. It’s always better to treat something on the early side than on the late side.
RC: That sounds good. Well, thank you for your time today Dr. Leiber. Hopefully, we’ll get some more questions that we can email to you. So if you do have any questions please drop them in the comments and I’ll be sure to get Dr. Leiber to come back to you, but he’s back off to clinic now, so thank you very much.
JL: Thank you, I appreciate it.