Can "Stem Cell" Treatments Help Athletes?

Rick Lehman, orthopaedic surgeon, medical director, U.S. Center for Sports Medicine, former team physician: Florida Panthers, Tampa Bay Lightning, St. Louis Blues, St. Louis, Mo.

Scott Rodeo,orthopaedic surgeon, co-chief, Sports Medicine and Shoulder Service, Hospital For Special Surgery, associate team physician, New York Giants Football, New York, N.Y.

Yankees pitcher Bartolo Colon reportedly received a novel stem cell remedy to treat his ailing shoulder and elbow, and has since returned to pitching. Ira Flatow and guests discuss the use of such treatments, and the controversy over using untested therapies in pro athletes.

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IRA FLATOW, host: You're listening to SCIENCE FRIDAY. I'm Ira Flatow. A year ago, Yankee pitcher Bartolo Colon was no longer pitching for a major league team. Closing in on 40 and plagued with injuries, it seems like the former Cy Young winner's career was just about over.

But after signing with the Yankees this year, Colon's career seems to be in full swing again. He's won five games. He has an ERA, an earned run average of 3.1, and although he's currently sidelined by an injured hamstring, he's on pace for a better season than he's had in years.

What happened? Well, we're not quite sure because his amazing comeback is being attributed, at least in part, to a controversial medical treatment, a treatment involving injecting cells taken from his own body back into spots where he has injuries. The cells then repair the damage.

Colon reportedly had the procedure in April of last year in the Dominican Republic, and while the procedure is not itself illegal, Major League Baseball is looking into it to make sure no banned substances like human growth hormone were used.

Joining me now to talk more about it are my guests. Rick Lehman is an orthopedic surgeon and medical director at the U.S. Center for Sports Medicine. He's the former team physician for the Florida Panthers, the Tampa Bay Lightning and the St. Louis Blues, and he joins us from St. Louis. Welcome to SCIENCE FRIDAY, Dr. Lehman.

Dr. RICK LEHMAN: How are you?

FLATOW: Fine, how are you?

LEHMAN: I'm good.

FLATOW: Scott Rodeo, MD, is an orthopedic surgeon and co-chief of sports medicine and shoulder service at the Hospital for Special Surgery here in New York. He's also associate team physician for the New York football Giants. Thanks for talking with us today, Dr. Rodeo.

Dr. SCOTT RODEO: Thanks for having me.

FLATOW: Rick, can you - what do you know about the Colon treatment - because it really has not been published very much, has it?

Well, I think it hasn't been published in terms of exactly what happened. I think people can put the pieces together, and went down to the Dominican and had a combination therapy. I think he had stem cell and probably PRP and then was re-injected with PRP about six weeks later and had it both in his elbow and both in his shoulder.

LEHMAN: And what no one really seems to know, and maybe Dr. Rodeo knows, is whether he also had an arthroscopic evaluation at the same time.

FLATOW: Let's get into some details about what you mentioned. The stem cells, where were they taken from, where were they put?

LEHMAN: In his situation, they were taken from fat. We normally take them from bone marrow. And they were put in his elbow, in his shoulder, in the areas of his rotator cuff and in the area of his ulnar collateral ligament or the inside ligament in his elbow.

FLATOW: And what happens, the stem cells then repair the damage?

LEHMAN: Well, stem cells are precursor cells or very immature cells, and they're going to recruit blood supply, and they're going to supposedly enhance the healing of the ligament, the rotator cuff, which is a tendon, and the ligament, and improve the healing mechanics, allowing the tissue, the damaged tissue, to heal certainly much better than it would heal in conventional, in a conventional manner.

FLATOW: And then you mentioned PRP. What is that?

LEHMAN: Platelet-rich plasma, and that's a technique where the athlete's blood is drawn, spun down. It's then re-injected into the injured area, trying to, again, take the elements, the cytokines, the things that help heal tissue, et cetera. So in a hamstring tear, in a rotator cuff tear, you're trying to enhance the healing process.

FLATOW: 1-800-989-8255, if you'd like to talk with us about sports medicine and specifically about using stem cells for treatment, PRP. Also, you can tweet us @scifri, @-S-C-I-F-R-I. Dr. Rodeo, I know there are some experts who take issue with calling these actually stem cells. What is your view on this?

RODEO: Right, this - I mean, there's a lot of variability when you talk about these kind of cells and cell-based therapies. Cells can be - a true stem cell, kind of by definition, to be a stem cell means the cell can self-renew, it can kind of renew itself, and it can differentiate into a number of specialized cells in the body.

And there's wide variability in the ability of different types of cells to do that. So, you know, truly cells that are embryonic, or so-called pluripotent cells, can(ph) conform most, but not all tissues on the body. Most of these cells are taken from adults, such as in this case - I don't know any details about Colon, so I can only comment generally - but cells taken from fat or bone marrow, as Dr. Lehman mentioned, those are typically multipotent cells.

That means they can generate a limited number of cells, you know, cell types in the body. So tremendous variability. When you talk about stem cells, we need to really define what are we talking about, and that's part of the difficulties in studying in this area, is there's such tremendous variability in the types of cells that are used.

FLATOW: Dr. Lehman, how common are these treatments, especially ones about the so-called stem cells?

LEHMAN: Well, I think they're common or becoming more common, and I think they have been used for a period of time. I think initially people used this PRP - and again, the research is all over the place in terms of does it help, does it not help, does it enhance healing - and as things sort of progress, people then started using either bone marrow with the PRP or fat cells with the PRP, again trying to recruit other stem cell lines or other cell lines, as Dr. Rodeo said.

And I think it's becoming more and more common, and I think the science behind it is probably becoming a little bit more and more murky, but...

FLATOW: Well, isn't that a dangerous thing, to have murky science, doing this on people?

(SOUNDBITE OF LAUGHTER)

LEHMAN: Dr. Rodeo wrote sort of the key paper on this, and I think the paper is a great paper, trying to really understand what's happening. I don't think it's unsafe, because you're taking Bartolo Colon's cells and injecting them back into Bartolo Colon. So I think from a safety standpoint, I don't think it's unsafe.

Is it efficacious? Is it going to enhance healing? I think that's the real question, and that's something that we will come to understand.

FLATOW: Dr. Rodeo?

RODEO: No, it's well-stated. I agree 100 percent. I think that - I think I'll start by saying I think it's a compelling - you know, the underlying biologic rationale makes sense. It has tremendous potential. It is safe. It's - you know, cells, or blood in the case of PRP, from the individual. There's just a lot we need to know more about the exact cell types we're putting in.

You know, each - my cells are different than your cells. So how do an individual's cells really function? What do we really put into the body in different sites, and then how do we stimulate those cells? PRP, exactly, might ultimately combine PRP, which brings in the different growth factors and things, with cells.

So cells by themselves may not be enough. The PRP by itself may not be enough. The two together may have some real potential. We just need better data as to how to best use this for different anatomic sites. Different tissues are different as well.

FLATOW: Why is there no good data? Why are there no good studies about that?

RODEO: We have a good amount of animal data. Human data, though, is much more limited. Well, it's hard to do high-level studies. Frankly, it's a newer technique as far as some of the contemporary techniques have only been around for a couple years. Studies are costly, and I think we've identified now what the important variables are, and now we need to do those studies.

We simply need to collect careful data on our patients. As Dr. Lehman mentioned, they're being used a fair amount, and that's probably fine, they're safe, but I would just advocate that we carefully study those patients in whom we use this and really look at what we're putting into the patients so that we can truly understand what is effective, what is not, what parts are effective, to really start to have a more refined understanding of this whole area.

FLATOW: Dr. Lehman, is it ethical to do these things on people if you can't say to them, you know, this is going to work?

LEHMAN: Well, I think, first of all, it's ethical if you explain exactly what the technology is, what you're doing, what the expectations are, and you're very, very honest with the information that's out there. So yes, I think it's ethical.

And in Bartolo Colon's case, and in many athletes' cases, there's really not a whole lot out there for a 37-year-old pitcher who's pretty much done. So if this is your only shot and the one thing that may make a difference, rotator cuff surgery on a 37-year-old pitcher or any pitcher is probably not going to work all that well. So I think yes, it's ethical.

And I think as - there are sort of two things. One is Dr. Rodeo is right, the basic science research has to be done. And then I think we need to do clinical research, and that is double-blind studies looking at these patients, the human people, and saying are they really any better than our conventional rotator cuff repairs.

My personal opinion is that they are, and I think our results are better since we've been doing it, but again, that's - what I say isn't really science until we've studied it in a true study.

FLATOW: Dr. Rodeo, do you agree that the stem cells, the PRP stuff, does give positive results?

RODEO: Yeah, I've seen some positive results. I think there's, you know, a fair amount of variability out there, but I think there can very much be positive results, and I would be optimistic about it. I think, you know, we need, we just need more information as to really the best cell type, and that may vary for different anatomic areas.

You know, if you're injecting a shoulder versus an elbow or different tissue types within a given joint, so it's a lot of variables to understand still.

FLATOW: There was some - the - baseball is investigating and interested in it not because it might be an illegal procedure, but possibly there was the use of human growth hormone, which is a banned substance in baseball. Why would that be mixed into this cocktail of what's happening? What would be the advantage of that if it was at all used?

RODEO: Well, I think growth hormone in general, you know, people - athletes use, people have used for years, athletes have used for years. And clearly people feel that that's going to enhance your rehab and enhance your ability to strengthen.

I think the other issue, though, is you've got a pitcher and a part-owner of an NHL team, and your athlete goes to the Dominican Republic. You have a contract, et cetera, et cetera, and then your athlete is kind of out of your care and treatment. So I think there are some other issues.

But in terms of the HGH, it's a banned substance. It's illegal. It's certainly, in most athletes' mind, would enhance the healing and improve your strengthening. And if that were, in fact, used, and Dr. Rodeo could talk more about this, I got to think that that's going to be a big problem.

Yeah. I agree. I mean, the rationale to use it would be, you know, HGH has a really positive effect on cell - basic cell physiology, cell proliferation, matrix synthesis. It could actually help stimulate the cells you inject. Certainly, HGH, we know by itself could have a positive effect. So - but at the same time, it's a banned substance. So I don't know the details in Bartolo Colon's case, but it's a banned substance.

LEHMAN: Yeah.

RODEO: And so, you know, and it makes hard to interpret the effect of any cell therapy if you also have another factor that may have contributed or lead to the positive result.

FLATOW: Dr. Lehman, we talked here on the show about using pluripotent stem cells to treat diseases, and one of the concerns that came up is tumors. You get cells that can divide uncontrollably. How do you know that this wouldn't cause a tumor in these kinds of cells that are being used?

LEHMAN: Well, again, I think if you have cancer cells, cancer cells are, again, cells that are dividing rapidly. Maybe they're in an area that are - that's anomalous. Maybe it's an aberrant cell line. I think when you're taking bone marrow aspirate and you're taking PRPs - so you're taking blood products in a cell line and you're injecting them, I don't really think that there's any increased chance that you're going to create a line of cancer cells. That just wouldn't be scientifically based. If you have cancer and you were to take that cell line and inject it into the shoulder, yes, you're going to have some kind of transfer of the cancer cells. But to take a bone marrow aspirate in a healthy athlete, which is a normal cell line, and then a PRP blood product, I really don't think there's any risk at all for causing cancer or creating an aberrant cell line.

FLATOW: Dr. Rodeo?

RODEO: Yeah. I could say that the issue comes up with very, very undifferentiated, you know, very primitive cells, that that risk is there. That risk could only be, you know, that the most primitive cells are cells that come from a fertilized, you know, fertilized egg. Those are truly - those cells can make any cell type in the body. Then your next level is embryonic stem cells, where there may be some risk. What we're talking about here, these are adult-derived cells. The risk is essentially minimal or no risk, because these are so-called multipotent cells. These are - they're much more limited in their ability to form different types of tissue, and as such, the tumorigenicity is minimal, and really not been a big concern.

FLATOW: Carol in Lovell, Wyoming. Hi. Welcome to SCIENCE FRIDAY.

CAROL: Hi.

FLATOW: Hi, there.

CAROL: I just wanted to say that I think you should have a veterinary person on the show today, because the stem cell and IRP and all of those therapies that you're talking about have been used for years in equines very successfully. Your big equine athletes are having that type of therapy all the time.

FLATOW: Yeah. We...

CAROL: And in fact, I - go ahead.

FLATOW: I know. I'm just going to say we did. We once had - we once talked about this with a veterinarian. She was telling us about how she had used stem cells in treating horses. So...

CAROL: Well, for instance, I have a mare who is a dressage, you know, competitor, and she had a subchondral bone cyst on the weight-bearing portion of her femur, and they took - they did orthoscopic surgery. They reamed that out. They harvested stem cells from her butt...

(SOUNDBITE OF LAUGHTER)

CAROL: ...from the fat, and injected those into that bone cyst. And it had beautiful healing, and she's completely sound now, where she was quite lame before. It's funny, because I have a human friend that had the same type of cyst in his knee, and they used the old technique of boring into the bone to stimulate bone growth because they couldn't use the stem cells and inject those because it wasn't legal, I guess.

FLATOW: Yeah, yeah. All right. We've got to run. We're running out of time. Thank you for sharing that with us. We're talking about stem cell treatments on SCIENCE FRIDAY, from NPR. I'm Ira Flatow talking with Rich Lehman, and also talking with Dr. Rodeo. Dr. Rodeo, what do you think about that? It's used in animals all the time. Is it, Scott?

RODEO: Yeah. Actually, I'm - and she makes a very good point, and I'm very familiar with the literature. There's some great literature used there, in particular for tendon-type disorders, kind of chronic tendonitis in horses. There's some very nice work done at Cornell University up in Ithaca and other places. Yup. I totally agree, and we've learned a lot from that, frankly.

FLATOW: And could - why not just use this in athletes if it does pan out? And this is also - is being tried and you can, you know, convince people to do really good testing about it, could you not use this for different parts of the body than just the, you know, the shoulders or the knees and things?

RODEO: You surely could. I mean, the biologic rationale is very compelling. It has great potential. You know, in our area, we look at it for healing meniscus and cartilage and tendon and ligament and certainly bone, as was mentioned. So, again, great potential. We just need to learn more about, you know, particular cell types for different tissues, how to stimulate them. It could have probably different - different requirements for different tissue types.

FLATOW: And who would do the research? Is, you know, drug companies usually do drug research because they can sell a drug. I mean, is that one of the problems here? There is really no big money to be made on doing something like this?

RODEO: Good question. There are some, you know, there are commercial systems that are available to help one do this, so there is some commercial part of this. I think good research should be done, you know, in your academic medical centers, where it's frankly done independently - independent from research. But at the same time, research is expensive. So we need funding from our, typically, you know, federal dollars from the NIH or private foundations, so you bring up a good point. We need research.

FLATOW: Rick Lehman, what would it cost if I came to you and I wanted to have this done? What would a typical price for this to be, if I'm an athlete or just someone who has a bad problem?

LEHMAN: Well, we charge probably about $400 for a PRP injection, and we charge about $700 to add the bone marrow aspirate for the stem cells. And there are products on the market, and they're emerging, ACell, which is an extracellular matrix from pig bladder. So Dr. Rodeo's right. And there's going to be private industry that will benefit from this if - as this technology progresses. But as a technology right now, it's expensive. I mean, all medicine's expensive, but it's not crazy expensive. It's not like a cancer drug or certain technologies.

So although $400 for a PRP injection is expensive, you may have one PRP injection or two PRP injections at the most, or you may put some PRP on a sponge and some bone marrow aspirate on a collagen graft and incorporate into a rotator cuff repair, it's not crazy, out-of-the-realm-of-reality expenses.

FLATOW: All right. Gentlemen, I want to thank you for taking time to talk with us today. Good luck to you.

RODEO: Thank you so much.

LEHMAN: Thanks. Take care.

FLATOW: Rick Lehman is orthopedic surgeon and medical director at the U.S. Center for Sports Medicine. Scott Rodeo is an orthopedic surgeon and co-chief of sports medicine and shoulder surgery - shoulder service at the Hospital for Special Surgery. We're going to take a break. When we come back, we're going to talk about growing solar power. Very quietly, a lot of solar power is being developed, maybe coming to a block near you, or to your electrical plug. We'll talk about it after this break. Stay with us. I'm Ira Flatow. This is SCIENCE FRIDAY, from NPR.

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