Ruben Berrocal Timmons^1*, Kiminobu Sugaya², Joel Isaias Osorio  Garcia³, Roy   Charles   Korth⁴, Blake Charles Korth⁵, Joseph Story⁶ and Charles David Sly^7*

¹Medical Doctor, Regenerative Medicine  and Pain Medicine  Physicians, USA

²Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, USA

³Medical   Doctor, Founder    & CEO    at Regenerage Clinic and Regenerage Life     a Regenerative Translational Medicine   Initiative, Greater Chicago Area, USA

⁴Doctor of Chiropractic, Founder of Buckeye Physical Medicine and Rehabilitation, USA

⁵Clinical Research Assistant, Buckeye Physical Medicine, and Rehabilitation, USA

⁶Medical Doctor, Faculty Associate University West Florida, USA.

⁷Doctor of Pharmacy, Buckeye Physical Medicine and Rehabilitation, USA

*Corresponding Authors: Ruben Berrocal Timmons, Medical Doctor, Regenerative Medicine, and Pain Medicine  Physicians, USA

Charles David Sly, Doctor of Pharmacy, Buckeye Physical Medicine and Rehabilitation, USA.

Accepted Date: 10-23-2021; Published Date: 11-24-2021

Copyright© 2021 by Timmons RB, et al. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Context: Injection with homologously-used umbilical cord tissue allograft has not been adequately studied in patients suffering from knee pain.

Objectives: The goal of this study is to determine if knee pain subjects who received cryopreserved umbilical cord tissue (UCT) injected into knee joints experience less knee pain, better function, decreased physical limitations, and reduction of medications (e.g., opioid, NSAIDs, and acetaminophen) over a 6-month period.

Methods: Prior to initiation of this study, Institutional Review Board (IRB) approval was obtained. Visual Analog Scale (VAS), Western Ontario and McMaster Universities Osteoarthritic Index (WOMAC), and medication usage data were recorded for thirty (30) consenting knee pain subjects receiving UCT at a single site in the United States. Subject profile information was also gathered and utilized to gain further insight into any effects of age, gender, and BMI on pain improvement over time.

Results: Mean resting VAS scores improved from 1.95 to 0.83 over 6 months (p<0.001), while mean VAS scores with activity improved from 6.28 to 2.87 (p<0.001) for the same period. There was no strong evidence of correlation found between gender and VAS scores (resting or with activity). However, there were statistically significant correlations found for both BMI vs. Pre-injection VAS with activity scores (r=0.402, p=.028) and Age vs. Pre-injection VAS with activity scores (r=0.434, p=.017).

Mean WOMAC daily activity function scores improved from 44.7 to 18.5 over the same 6 months (p<.001).

Overall, of the patients who used medications at the beginning of the study (18), 77.8% of them reduced or eliminated medication use.

Conclusion: Analysis demonstrates that injection with UCT decreases pain, improves physical function, and allows for less medication use for at least 6 months.

Keywords

Umbilical cord tissue; UCT, knee pain; VAS; WOMAC. 

Introduction

Osteoarthritis (OA), the most common type of disease affecting joints, is one of the most predominant causes of chronic pain and disability in developed nations, including the United States. Specifically, knee OA represents over 80% of the types of osteoarthritis, affecting almost one fifth of American adults over the age of 45 [1]. Almost 23% of US adults (an estimated 54.4 million people) report having doctor-diagnosed arthritis. Even without doctor diagnosis, almost half of American adult’s experience limitations in performing their activities of daily living secondary to arthritis [2]. In recent decades, high body mass index (BMI) has become rampant in the United States. Being overweight or obese is a risk factor for knee OA, due to joint overloading as well as adiposity-induced inflammation [1]. Based on analysis of data from 2010-2012 from the National Health Interview Survey (NHIS), it is projected that 26% of adults will be diagnosed with arthritis by 2040. Arthritis and other rheumatic conditions are a leading cause of work disability among US adults [2]. Adults with arthritis are almost three times more likely to fall and suffer injury compared to their non-arthritic counterparts [3]. Of knee and hip OA patients, 25% cannot perform major daily activities and 40% report fair to poor health, ranking high in disability adjusted life years [4]. Because knee pain limits physical activities such as walking, bending, and climbing stairs, reducing pain could improve physical activity and conditioning [5].

Senescing joint tissues accumulate more cartilage loss due to inflammation, oxidative stress, and activation of matrix metalloproteases (MMP) [6]. Joint replacement surgeries are most often due to OA [7]. Considering both direct and indirect costs associated with OA, average annual costs from 2008-2014 totaled$486.4 billion. In 2013, the OA treatment costs were $140,300 [8].

Existing treatments for joint pain are limited to medical management, injection therapy and surgery. Medications to reduce pain are associated with significant morbidity and social concern. 10.1 million people over the age of 12 misused opioids over the course of the year 2019, the overwhelming majority of which abused prescription pain relievers. Of those, approximately 1.6 million over age 12 were diagnosed with an opioid use disorder [9]. Health care providers face increasing burden and cost of chronic opioiduse with increased scrutiny of monitoring patient usage and protecting against abuse. Almost 500,000 deaths were attributed to opioid overdose, including prescription and illicit opioids, from 1999-2019 [10].

Non-steroidal anti-inflammatory drugs (NSAIDs) are often the first line of treatment chosen by patients with chronic pain. Hospital admission rates due to upper and lower gastrointestinal events secondary to NSAID and aspirin drug use was significant with a mortality rate of almost 6% of admitted patients. About 30% of these deaths were attributed to use of low-dose aspirin [11]. While most common NSAIDs have little toxic effect, NSAID use and overdoses continue to increase, as reported by poison control centers nationwide.

Adverse drug interactions, especially in vulnerable patients, increase morbidity and mortality [12].

While steroid injections provide short-term relief of pain, side effects such as diabetes exacerbation, weight gain, cataracts, osteoporosis, difficulty sleeping, menstrual changes, and increased risk of infection should be considered [13]. Disease-Modifying Anti-Rheumatic Drugs (DMARDs) may also increase the risk of infection and can cause liver or kidney damage. Some patients do not tolerate DMARDS, and they may not be safe for those who are or are trying to become pregnant [14].

Finally, surgery for joint replacement associated with chronic pain is very costly and may have a limited effect on pain and disability [7,8]. Given the high cost, limitations, and side effects associated with traditional methods of treatment of chronic joint pain, alternative approaches to relief are needed.

Background on Umbilical Cord Tissue. Umbilical cord tissue (UCT) is clinically available from registered tissue banks globally. The form and methods for preparing umbilical cord tissue allografts may vary affecting the specific contents and clinical results.

UCT from healthy live births contains regenerative, anti-inflammatory, immunomodulatory and wound healing properties due to the many growth factors and cytokines present in UCT at a higher concentration than in other biologics. These may play a factor in their inflammation-reducing, pain-reducing, and musculoskeletal-healing properties [15, 16]. UCT contains prostanoids PGE2, IL-10, VEGF, and TIMPs that suppress cartilage damage. These proteins exhibit potent anti-inflammatory and anti-fibrotic effects in OA joint disease. [17, 18]. Of relevance to OA, PGE2 “reprograms” macrophages from the inflammatory M1 phenotype to the anti-inflammatory M2 phenotype [19].

UCT stimulates many metabolic processes including general protein and collagen synthesis, reducing pain. UCT is safe in humans and animals. Uses of UCT include burn and painful chronic wound healing as well as in shoulder, foot and ankle surgeries [20-23].

Placental, as well as umbilical cord tissue donated by volunteers free of communicable disease undergoing caesarian section, is processed to obtain UCT. The UCT is minimally manipulated under aseptic conditions and cryopreserved with DMSO, retaining much of its original matrix microstructure and cytokine profile. The cryopreserved UCT is used homologously as a protective barrier or cushion of membranous tissue placed in or over damaged joint tissue in patients with osteoarthritic joint pain. Patients receiving UCT for joint pain have failed previous conservative and conventional therapies such as pharmacological and physical therapy, making it medically necessary to proceed with interventional treatment.

Background on Ultrasound-Guided Knee Injection Utilizing the Lateral Supra Patellar Approach.

After patient education and consent, the patient underwent an ultrasound-guided supra patellar injection utilizing 1 ml of thawed cryopreserved UCT along with 4 ml sterile normal saline under direct ultrasound visualization after the knee was prepped with ChloraPrep. 

The post-procedure evaluation involved alertness, pain, stable vital signs, and unchanged neurologic status at 15 minutes and 60 minutes. After postoperative instructions, the patient was discharged in stable condition. While UCT injections in the knee are a daily clinical practice at this institution, outcomes have not been previously reported.

Methods

To report the outcomes after injection of UCT for joint pain, medical charts of 30 consenting adult subjects with knee joint pain previously treated with UCT at a single institution were reviewed for Visual Analogue Scale (VAS) pain scores, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) daily activity function, opioid usage, and NSAID usage as well as for serious adverse events under an IRB- approved protocol.

Pain was evaluated using the VAS as assessed by the patient at baseline, 1 hour, 24 hours, 1 week, 2 weeks, 8 weeks, 12 weeks, and 24 weeks for both resting scenarios and with activity scenarios; this was consistent with the standard patient follow-up schedule at this institution.

Pain, stiffness, and physical function were assessed using WOMAC questionnaire at baseline, 2 weeks, 8 weeks, 12 weeks, and 24 weeks.

Presence of opioid, NSAID usage, and other medications were recorded at baseline, 24 hours, 1 week, 2 weeks, 8 weeks, 12 weeks, and 24 weeks. 

Results

Medical records for 30 patients provided substantially complete data regarding demographics and outcomes. The mean age was 63.0 ± 10.9 years, range 36-84. 

Table 1 shows the details of patient age versus gender. 

Table 1: Patient Age vs. Gender Summary. 

There was no strong evidence of difference found between Genders and VAS scores (resting or with activity) at the 6-month review, based on independent sample T-tests. See Figure 1. Gender vs. VAS (Rest, Active) for details.

Figure 1: Gender vs. VAS (Rest, Active) Independent Sample Tests.   

However, a statistically significant correlation was found between Age and the Pre-injection VAS (resting) score (r=0.434, p=0.017), showing higher Pre-injection VAS (resting) scores for older patients. See Figure 2. Age vs. VAS Correlation Test Results for details.

Figure 2: Age vs. VAS Correlation Test Results. 

Two-thirds of the patients received treatment for their right knee, and one-third received treatment for their left knee. Table 2 shows the details of patient gender versus injection (treatment) sight.

Table 2: Injection Sight vs. Gender Summary. 

The Body Mass Index (BMI) for the patient population was 29.2 ± 7.0, range 18.0-50.2. 

Table 3 shows the details of BMI versus gender.

Table 3: Patient BMI vs. Gender Summary. 

A statistically significant correlation was found between BMI and the Pre-injection VAS (active) score (r=0.402, p=0.028), showing higher Pre-injection VAS (with activity) score for higher BMI patients. See Figure 3. BMI vs. VAS Correlation Test Results for details.

Figure 3: BMI vs. VAS Correlation Test Results. 

Mean VAS scores (resting) improved from 1.95 to 0.83 over 6 months (p<0.001), while mean VAS scores (with activity) improved from 6.28 to 2.87 (p<0.001) for the same period figure 4.ANOVA tests with Tukey HSD Analysis were conducted for VAS at rest scores over the 6-month period and VAS with activity scores over the 6-month period. Results from those analyses revealed:

• Mean VAS scores with activity were statistically different (higher) than the mean VAS scores at rest for every time interval,

• When comparing the mean VAS scores with activity(Figure 4), there was a decrease in the mean for VAS with activity scores after the injection:

*A 1 hour evaluation with activity was not recorded; this comparison is an at rest score to scores with activity. 

• The p-value for the ANOVA for VAS scores with activity was 1.18 x 10-15.

• Comparing the mean VAS scores at rest revealed that the mean VAS score pre-injection was statistically different (higher) than the mean VAS scores at all other time intervals, but there was no statistical difference in the means for all the post injection scores. Overall, there is a decrease in the mean for VAS at rest scores after the injection, and

• The p-value for the ANOVA for VAS scores with at rest was 0.000561.

Graphical representation of the Mean Plots with 95% CI for VAS scores (at rest and with activity) is shown in Figure 4. In addition, ANOVA test results for the VAS scores (at rest and with activity) over time are provided in Figure 5 and Figure 6.

Figure 4: Mean Plots of VAS Scores (Resting and With Activity) with 95% CI.

Figure 5: ANOVA Results for VAS at Rest Scores over Time.

Figure 6: ANOVA Results for VAS with Activity Scores over Time. 

The Mack-Wolfe Test is a non-parametric technique used to test for a “U” or “Umbrella” shape in the median (i.e., a peak or valley). It works even when the curve is very non-symmetrical about the valley (i.e., when a quadrative regression would not fit well). Execution of the Mack-Wolfe Test on the VAS scores revealed that there was strong evidence of a valley in the VAS (resting) score median at 2 months and a valley in the VAS (with activity) score median at 2 weeks. See Figures 7 and 8 for graphical representation of the Mack-Wolfe Test results for the VAS scores at rest and with activity, respectively. 

Figure 7: Mack-Wolfe Test Results for VAS (at rest) Scores vs. Time Since Injection. data: x and g Ap*=-3.0623, p-value=0.008 alternative hypothesis: theta_1<=...<=theta_p>=... >=theta_k, p=5 (the fifth bar graph).

Figure 8: Mack-Wolfe Test Results for VAS (with activity) Scores vs. Time Since Injection. Data: x and g

Ap*=1.9614, p-value=6e-04 alternative hypothesis:theta_1<=...<=theta_p>=...>=theta_k, p=4 (the fourth bar graph. 

Plotting VAS scores over time revealed a slow linear increase with much uncertainty (p=.1972), suggesting further data needs to be collected over a longer period to draw a strong conclusion; however, this model suggests it would take an estimated 1162 days (3 years, 2 months) to return to Pre-Injection VAS with activity scores without further intervention. (See Figure 9).

Figure 9: Linear Analysis of VAS Scores with Activity and Estimate of Time to Return to Pre-Injection VAS Scores. 

Estimating Time to Return to Pre-Injection VAS Scores

Visually, from Day 1 post-injection it appears that there is a slow increase in VAS over time. Therefore a linear model was fit. The p-value of model=0.1972 indicating lots of uncertainty in the slope estimation suggesting data needs to be collected over a longer period of time (ex. 2 years), however it gives us a ballpark estimate of the longevity of this treatment. A quadratic model was tried but it did not improve the model fit. The Model is below:

Activity VAS= 2.416+0.003326 (Days Post Injection)

Given that the average Pre-VAS score is 6.28333 we estimate that it takes about 1162 days post-injection (3 years and 2 months) for VAS scores to return to back to pre-Injection levels, on average.

Days to Return to Pre Injection Scores = Activity VAS- 2.416/.003326=6.28333-2.416/0.003326= 1,162 Days. 

WOMAC-measured physical function scores improved from 44.7 to 18.5 over the 6-month review period (p<.001). Table 8 summarizes WOMAC data over time.

Table 5: Summary of Womac Data Over Time. 

ANOVA for WOMAC scores over the 6-month review period revealed that the mean Pre-injection WOMAC score is statistically different from the mean WOMAC scores at 2 weeks, 2 months, 3 months, and 6 months. This is supported by a p-value of 1.34x10-6. Otherwise, the mean WOMAC scores at 2 weeks, 2 months, 3 months, and 6 months are NOT statistically different from each other. Graphical representation of the Mean Plots with 95% CI for WOMAC scores is shown in Figure 10. In addition, Paired Sample test results for the WOMAC score over time is provided in Figure 11.

Figure 10: Mean Plot of WOMAC Scores with 95% CI.

Figure 11: Paired Sample Test Results for WOMAC Scores over Time.

Table 6: Summary of Drug Types Used by Patients Throughout Study. 

Overall, of the patients who used medications at the beginning of the study (18), 77.8% of them reduced or eliminated medication use. 

Table 6 shows the number of patients using a particular drug/drug combination at each point in the study period:

Analysis of medication use by patients over the study period revealed

• 30%(9) of the patients studied never took medication throughout the course of the study period,

• 13.3%(4) of the patients studied continued to take medications throughout the entire course of the study period,

• 20%(6) of the patients studied went from daily medication use to no medication use by the end of the study period,

• 13.3%(4) of the patients studied reduced their medication frequency from daily to occasional by the end of the study period,

• 13.3%(4) of the patients studied reduced their medication frequency from occasional to none by the end of the study period,

• One person went from using no medications to using CBD oil on the knee at the end of the study period.

Although that patient had decreasing WOMAC and VAS at rest scores throughout the study period, their VAS with activity score did not change significantly throughout the study period (VAS range: 3-4).

• One person went from using no medications to occasionally using Tylenol at the end of the study. This patient's VAS and WOMAC scores remained consistent throughout the study.

• One person went from using no medications to using Tylenol or Ibuprofen daily. This person's VAS and WOMAC scores initially decreased after the injection, but increased back up over time to pre-injection scores, and

• The number of patients using opioids decreased by 16.7% from pre-injection to 6-month follow-ups, and the number of patients using NSAID decreased by 46.1% from pre-injection to 6-month follow. (See Figure 12).

Figure 12: NSAID and opioid use after treatment. 

Medication data was made binary at time 6 months (any medicine vs. none).

A Welch two-sample t-test showed strong evidence of a difference for VAS with activity scores and those using medications; that is, subjects using medications reported higher VAS active scores (p-value=0.064).

No serious adverse events were reported throughout 6 months. Between 2 weeks and 2 months, one patient fell and reinjured the knee and was reinjected at 5 months. Late intervention was without complications. All three outcomes depict a consistent result with significant improvement. Extended follow-up is expected at 360 days for all patients.

Discussion

Chart review of 30 patients with joint pain revealed the clinical benefits of injecting UCT for knee pain. Improvement in pain, physical function, reduction in medications (opioid use and NSAID) use began promptly after treatment and was sustained over at least a 2-week period, in most cases extending to 6 months. Given that opioid use is a CDC national epidemic secondary to dependency, overdose, and abuse, leading to reluctance in prescribing and difficulty in managing patients on opioid, UCT offers an important alternative [9, 10].

In many instances, patients were physically limited and deconditioned secondary to their pain. Counseling on weight reduction and transition to physical activity is a critical adjunctive measure in achieving improvement in normal activities of daily living. Prior to treatment, many patients exhibited increased BMI as well as were physically deconditioned. This, in fact, is a factor that may complicate or hinder recovery and functional restoration. Therefore, it is crucial that patients be counseled on reduction of BMI for sustained outcomes.

This study demonstrated that the injections were effective for 6 months, however we have continued to follow these patients over the course of 2 years. We have observed that many go beyond 24 months of relief compared to baseline with just one injection. This is consistent with extrapolation projection as demonstrated in our ANOVA linear model (Figure 9).

While the cost of a single steroid injection is less expensive than a UCT injection, in a given year, a patient may receive up to four injections of steroid which increases morbidity associated with each injection. This is in comparison with UCT which would require only one injection and has not been associated with any adverse events or increased morbidity and may provide up to 2 years of relief.

While this review supports safety and efficacy, its limitation is that it is not a prospective randomized study against a control depicting the standard of care. It is extremely important that additional studies and confirmation of data substantiating pain relief and improved function be investigated in patients with arthritic joint pain before acquiescing to joint replacement.

Conclusion

UCT injection reduces pain, physical disability, medication usage (specifically opioid and NSAID usage) in patients suffering from knee pain for at least 6 months. As a result, this would allow patients to postpone or delay joint replacement until BMI and physical condition are optimized. 

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