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One common question about OCD is, 'Since everyone has weird habits, how is this any different?' With some exceptions, most people with OCD realize that they have these unusual habits but often feel powerless to do anything about them. The difference between habits and obsessive compulsions is that the latter take inordinate amounts of time to be completed, and patients must often follow strict self-enforced rules to enact the compulsions. For example, a patient with OCD may worry about the symmetry of objects enough that they can not do the next task in their day until all the items in a room are rearranged to become symmetrical. This kind of attention to detail may regularly take an hour or more each day.
Epidemiology
The Obsessive Compulsive Foundation estimates a 3% prevalence of OCD in the U.S. population, which equates to five million to six million people.1 OCD is more common in boys than in girls but roughly evens out in adulthood.2 This increased diagnosis in adult women could be because women are seen for health care appointments more often than men.
Approximately 30% of OCD patients have symptoms of hoarding. Hoarding is defined as the inability to throw away things of little to no value, combined with the continued accumulation of new items. In Massachusetts, health and public service agencies found that 0.26 cases of compulsive hoarding were reported per population of 1,000 in a five-year period.3 Certainly, not every patient who hoards is reported, so this likely represents the most severe cases.
Many elderly hoarders are female, unmarried and live alone. Some researchers hypothesize that this is a problem that only gets worse when patients with a tendency to hoard live by themselves, with no one to help curb this behavior. Never-married patients tend to have much worse hoarding symptoms. Also, some propose that this condition gets worse as people age.3
Hoarding
Most OCD patients who have hoarding behaviors tend to collect things such as newspapers, papers, food containers, food, clothing, books and sometimes items from other people's trash. In a 2001 study on 62 elderly hoarders, the authors report that nearly all clients had severe clutter in their living rooms, dining rooms, kitchens and bedrooms (92% to 96%).3 Thirty-six percent of study clients were described as having clean personal hygiene, while 17% were extremely dirty, even having 'blackening of the skin, filthy hair and soiled clothing.'3 This was presumed to be because clutter was severely restricting the client's access to the shower, bathtub or sink. Clutter in the 70% of the homes was found to be chaotic or very chaotic with no apparent organization. Another issue is that many patients who hoard do not want anyone coming in their homes for repairs, either from embarrassment if they have insight into the hoarding, or because some patients have accused service providers of stealing their possessions.3
'In some cases clutter was knee-high or higher, requiring elderly clients to climb over possessions to reach another location. One client was described as literally swimming over the top of clutter to reach other rooms. Nearly 70% of elderly hoarders were unable to use their furniture (for example bed or sofa).'3
Clutter could also prevent patients from performing normal food preparation or storage and could present major hazards to patients' health, in the manner of a fire hazard due to excessive flammable material. There is also the likelihood of tall piles of collected materials falling down on the patient. Conceivably, if patients live in apartments, the fire hazard could spread to other nearby dwellers. While this amount of clutter would be dangerous in any age group, the elderly are already more susceptible to limited mobility and falls. In any situation where a younger person could run to the door to escape a fire, a patient with a walker would be slower navigating a narrow escape path with piles of newspaper in the way.
Steketee, Frost and Kim hypothesized that they would find the clients had problems with memory and cognition. However, 76% were found to have no problems with cognition, and 67% had no problems with memory.3 This observation leads to the conclusion that these were true OCD patients without comorbidities of dementia.
Even though most OCD patients are aware that their obsessions and resultant compulsions are excessive, some patients, including many hoarders, are not very aware that they have a problem, or that they are not in control of the problem. This lack of insight in hoarders, and various other OCD patients has led to a poorer prognosis, probably due to decreased treatment seeking on the part of patients.4
Etiology-Pathophysiology
OCD is thought to be related to an imbalance of serotonin in the brain, partly because SSRIs have been found to be effective in this disorder. Serotonin acts to connect nerve impulses from one neuron to the next and also has an impact on repetitive behaviors. No specific genes have yet been found to explain the origins of OCD, but there seems to be a familial connection.2 Interestingly, it is the diagnosis of OCD that tends to get passed on and not all the same symptoms.2
About two-thirds of OCD patients have experienced major depression in their history. There is some debate in the field about whether OCD causes the depression or whether these are simply common comorbidities. A majority of patients report the OCD symptoms first, with the depression occurring after the OCD is out of control.2
Rarely, neurologic changes may be present in the OCD patient due to previous problems from an autoimmune reaction to a strep infection, a history of encephalitis or a head injury, but this is very unusual. However, there are some changes that can be seen on brain scans of OCD patients. One study even found that OCD patients had significantly more gray matter and less white matter than controls did. Positron emission tomography and functional magnetic resonance imaging have shown increased brain activity in the frontal lobes, basal ganglia and cingulum in OCD patients as compared to controls.2
To beat your Obsessive Compulsive Disorder
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Obsession rules
OCD cases don't come to us until they hamper the routine of daily life V. Ponni Muralidharan
DEALING WITH DISORDER
Lady Macbeth would have been a classic case. The ambitious wife of Shakespeare's Macbeth, who wrung the guilt off by perpetually washing her hands, must have had Obsessive Compulsive Disorder or OCD.
OCD, rated by the WHO as one of the top ten debilitating diseases and prevalent in 2.5 per cent of the Indian population, is beginning to shake off its "laughing matter" tag. Of course, I poked fun at the uncle who compulsively washed his hands every time he touched the gate "some beggars might have handled." But then, the other day when I scanned my plate for unseen dirt, I too was branded an OCD case!
But, what the heck! David Beckham has it. They say even Dickens and Darwin had it. Jack Nicholson tapped his feet to an Oscar with his portrayal of a writer with OCD in As Good As It Gets. And Tony Shalhoub in the tele-series The Monk combats unsolved cases as well as his obsession for order and cleanliness.
Jack Nicholson i As good as it.
Misconceptions galore
But despite the representation in the media, that mostly draws chuckles, OCD to a large extent remains undetected as it is still shrouded in misconceptions.
"The OCD cases don't come to us until they hamper the routine of daily life," says V. Ponni Muralidharan, consultant psychiatrist, KG Hospital.
P. N. Suresh Kumar, Director, Institute of Mental Health and Neuro Sciences, Kozhikode, is of the opinion that OCD remains an undetected problem as it is often mistaken to be a character trait.
He says "OCD is the recurrent, intrusive, disturbing thought, impulse or images occurring in the patient's mind in clear consciousness without any control."
The impulse could be anything. From the urge to tap the table thrice after every sentence, to placing your foot dead centre of the floor tiles, the feeling that clothes are dirty even after washing them repeatedly, the compulsive urge to check if the cooking gas is turned off or the door locked and so on and so forth to more serious obsessions.
"The commonest fear today is being infected by HIV," says N.S Mony, psychiatrist and points out that OCD is the fourth most common mental disorder in India.
Tony Shalhoub of The Monk fame.
According to the doctors, OCD is caused by a chemical imbalance in the brain ' the deficiency of serotonin. However, everyone with serotonin deficiency need not have OCD. But those with the deficiency are susceptible to it in the event of stress. Dr. Ponni observes that most people who create this intricate web of actions believe something may actually go wrong when this pattern is broken.
"Especially in children, who grow up in an overtly critical or judgemental atmosphere, these repetitive actions become a way for them to be in control," she says. Most kids tend to believe that a tragedy may befall their parents if the pattern ' which may be jumping twice even as they walk or placing their foot in the middle of the square of the floor ' is broken.
According to Dr. Mony, while OCD traits are seen from childhood, puberty or even during the teens, it is only when the disorder has peaked five to ten years later, that the doctor is consulted.
"And when they come it is often the tip of the iceberg," points out Dr. Suresh. "In these cases, adjustment is a problem. Celibacy rate is high among these people as they believe the spouse will not be able to adjust to their ways," he adds.
Psychiatrists have come across all kinds of cases, some of which may appear weird to lot of us. On a lighter vein Dr. Ponni notes "There was a surge in OCD cases when there was water shortage in the city. Husbands brought along wives who wasted water washing clothes all day." Then, there are those who believe their body is dirty and cannot make do even with a tank of water, or for whom a soap wouldn't last even a couple of days. These actions of cleaning or washing are often done at the cost of ignoring other important chores. OCD is also culture induced. Like the Suchibai syndrome said to be prevalent among Bengalis relating to their obsession with cleanliness.
Guilt trip
OCD also comes in the form of obsessive images or thoughts.
For example, "There are patients who have the urge to use abusive words when visiting holy places," says Dr. Suresh.
"And, this obsessive desire to use obscene words puts them in a position where they have to deal with the guilt," he explains.
Often, the recurring thought or the images transgress into the realm of the inappropriate thereby creating guilt once again.
"Since, these people are not perverts, the guilt makes it difficult for them to face people," explains Dr. Ponni.
The treatment for OCD is multi-pronged. Quelling the prevalent misconception that OCD is a kind of madness, Dr. Ponni clarifies "These are neurotic people who are not mad."
The treatment will involve both pharmacotherapy as well as behavioural therapy. The pharmacotherapy therapy is called Selective Serotonin Reuptake Inhibitors (SSRI) aimed at increasing the serotonin levels. And usually family therapy is also advised. "In rare cases a neuro-surgical intervention is also done," says Dr. Mony.
"OCD is 100 per cent controllable and the behaviour therapy has to continued," concludes Dr. Suresh.
To beat your Obsessive Compulsive Disorder
The mind and emotions will be the subject of next week's programme in the Klinika series. As usual Klinika airs live on Net Tv every Wednesday at 8.30pm with a repeat the next morning at 9.15am.
Mental and emotional problems can disturb the roots of a person's existence affecting their self esteem and ability to cope with the pressures of every day life.
Klinika will investigate a number of mental health disorders including phobias, anxiety and panic disorder as well as obsessive-compulsive behaviour. Our guest specialists will help us understand what phobias are and how people with genuine phobias can be severly restricted with their lives affected in many different ways.
Anxiety can also interfere with every day life. When this happens and anxiety becomes the usual response to ordinary situations, it is considered a disorder. Our guest psychiatrist, Dr. Joe Cassar will describe how panic disorder is a common, recurrent and unpredictable type of anxiety.
Finally we will see how with persons suffering from OCD (Obsessive Compulsive Disorder) unwanted thoughts enter the mind repeatedly and these often involve anxieties about safety, hygiene or security of possessions. These unwanted thoughts are often accompanied by anxiety and irresistible urges to carry out compulsive actions over and over again.
As usual Klinika will also describe how advances in our understanding of the way the mind and body are interrelated have led to new ways of coping with these disorders.
Treatment ranges from touch and movement therapies to drugs, nutritional supplements, psychological therapies and stress management techniques.
To beat your Obsessive Compulsive Disorder
An immense fear of germs and a powerful need for order and control led billionaire Howard Hughes to live the last years of his life as an eccentric recluse, a prisoner of his own biochemistry.
The film "The Aviator" shows how obsessive-compulsive disorder, a mental illness that affects two to three percent of Americans, can devastate lives. However, with a comprehensive hospital treatment program like the one available at The Menninger Clinic, an affiliate of Baylor College of Medicine in Houston, Obsessive-compulsive disorder patients with severe symptoms are successfully managing their disease.
"Obsessive-Compulsive Disorder causes anxiety provoking thoughts or urges, known as obsessions," said Dr. Joyce Davidson, medical director of the Menninger Obsessive-Compulsive Disorders Treatment Program. "These thoughts compel individuals to perform time-consuming rituals, known as compulsions, in an attempt to ease the anxiety."
According to Davidson, common obsessions and compulsions include:
A fear of contamination that leads to excessive hand washing.
A fear of causing harm that leads to repetitive checking.
A need for symmetry that leads to habitual arranging of objects.
Excessive doubt that leads to unrelenting requests for reassurance.
Resisting these thoughts and rituals is not easy and can actually intensify symptoms. Avoiding activities that spur obsessions doesn't work either, says Davidson, and has led some Obsessive-compulsive disorder sufferers to become homebound.
Although Menninger's Obsessive-compulsive disorder Treatment Program uses a variety of research-proven techniques to help fight the disease, one approach, known as Exposure and Response Prevention, is very effective. This intensive behavior therapy allows patients to confront their obsessions head on while overcoming the urge to perform rituals.
"If patients are reluctant to touch door knobs due to a fear of germs, we have them hold a door knob until their anxiety habituates," said Davidson, who is also an associate professor of psychiatry at BCM. "The other important step, `response prevention,' is executed when patients are not permitted to wash their hands afterward."
The cause of Obsessive-compulsive disorder is somewhat mysterious, though research proves that chemical imbalances in the brain are responsible. Davidson said Obsessive-compulsive disorder symptoms often improve when patients take Selective Serotonin Reuptake Inhibitors, drugs commonly used to treat depression.
"Individuals with OCD show the most improvement when these medications are used in addition to behavior therapy," said Davidson.
Beyond comprehensive behavior therapy, the program's treatment also includes:
Individual counseling
Group therapy sessions
Family education and support
Medication management
Treatment for coexisting disorders such as depression
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Dual Diagnosis
from by Kimberly Bailey
Issues with Diagnosis and Treatment"I made a serious commitment to quit all drug use (street & rx) when I was pregnant (7 years ago) which actually led to my diagnosis of BP, as I could no longer hide my illness without the drug use."
~from Elizabeth
"I stopped alcohol 5 years ago and street drugs four. Of course, this is when my depression (possibly BP with no formal dx) and OCD really began to peek out from beneath the foggy cover of my substance abuse camouflage."
~from Internalburn
For those struggling with a dual diagnosis, there are most certainly many challenges to diagnosis and treatment. First and foremost, even identifying both conditions presents problems. One study found that only 2% were detected of those with a substance problem among severely mentally ill patients seen in a university hospital emergency room. The state hospital did only slightly better, detecting 15% (Wolford, et al., 1999). This problem occurs for a number of reasons. Emergency rooms are just not often able to do structured interviews about drug and alcohol use. Patients tend to underestimate the problems caused by the drugs, and they rarely disclose that they have a problem with substance abuse (Wolford, et al., 1999). Practitioners should also keep in mind that illicit drugs and alcohol can cause the development, the reemergence or even worsen the severity of mental disorders. These drugs can also present symptoms that pararell those of mental disorders or even cover them up. Furthermore, Dr. Brady points out that "acute intoxications as well as withdrawal states can mimic affective illness" (1992).
In addition to these hurdles, there are many physical complications to treatment itself. Douglas Polcin outlines some major challenges in his article entitled "Issues in the Treatment of Dual Diagnosis Clients Who Have Chronic Mental Illness." He cites poor treatment response, high rates of rehospitalization, aggravated psychotic thoughts, and changes in neurophysiology. He also notes that those dually diagnosed are often less responsive to medications than those who do not abuse substances, specifically stating that cocaine users have problems with lithium (Polcin, 1992).
Another issue with treatment is that "systems have not been well designed with this population in mind. Typically a community has treatment services for people with mental illness in one agency and treatment for substance abuse in another. Clients are referred back and forth between them in what some have called 'ping-pong' therapy" (NAMI). Often the very treatment approach of one service may cause problems for the other side of the condition. For example, substance abuse workers traditionally consider the use of medications to be a crutch for those struggling with addiction. However, psychiatrists rely on prescriptions to treat the mental illness, and while psychiatrists rarely give much credence to spiritual or self-help approaches, those working with addictions place a great deal of emphasis here (Polcin, 1992). Poor communication is yet another problem. Those struggling to reach stability with their mental illness and to achieve sobriety are, more often than not, shuffled between different practitioners. Even when these counselors and doctors work within the same facility, there is seldom good, if any, communication between offices (Zweben, 1993).
A few years ago, the US Department of Health and Human Services outlined some specific areas for research. The first area relates to decision-making with regard to treatment plans. Second is the use of psychotropic medications. Accurate diagnostic tools is another area greatly needing research (Zweban, 1993). There is currently no good instrument for detecting or classifying substance use disorders in the mentally ill, in that those available were developed for use in the general population (Wolford, et. al., 1999).
In conclusion, a final question needs to be considered. With these facts and figures, the outlook for those with dual diagnosis seems grim. What is the long-term prognosis? Is there any hope for stability and sobriety? The lifetime prevalence of substance use disorders is as much as seven times greater for those with bipolar disorder than those in the general population (Knowlton, 1995). However, Linda, a member of our Forum Community, shares a ray of hope in this message: "My life is quite manageable today with the proper medication, therapy, a wonderful support program and recovery program. and no booze ... not a drop. Works the best I have ever had it."
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To beat your Obsessive Compulsive Disorder
We all remember as children how the boys didn't want to be touched by the girls because they had "cooties." All children have worries and doubts, but when they begin to obsess about them, it might hamper their ability to function.
"We all have little obsessions and compulsions here and there, but a diagnosis of Obsessive Compulsive Disorder isn't given unless the behavior begins to impede with how the child functions," said Dr. Thr?stur Bj?rgvinsson, an assistant professor of psychiatry and behavioral sciences with the Menninger Department of Psychiatry at Baylor College of Medicine in Houston. "The child may have trouble sleeping, check their homework over and over again, or not have friends over because they are afraid they might bring germs in the house."
Obsessive Compulsive Disorder is an anxiety disorder that if left untreated can take over a person's life. Children suffering from Obsessive Compulsive Disorder develop disturbing, obsessive thoughts that cause fear or anxiety. To get rid of the thoughts and relieve the fear, they perform rituals, which provide temporary relief.
Obsessions are recurrent and intrusive thoughts, impulses or images. Typical obsessions are: fear of dirt or contamination, concern with order, fear of harming a family member or friend and fear of thinking evil or sinful thoughts. Compulsions are repetitive behaviors such as, excessive hand washing or repeatedly checking things, and mental acts like repeatedly counting to the same number or praying, that they do in response to the obsession.
The biggest danger of not recognizing the symptoms of Obsessive Compulsive Disorder is that children might spend so much time trying to fight the disorder that they may fall behind school and their relationships may also suffer.
Bj?rgvinsson says the first line of treatment of Obsessive Compulsive Disorder is through a cognitive behavioral psychotherapy program called exposure and response prevention. CBT helps children confront their fears and find new ways of dealing with them.
"If a child fears touching books that aren't new, we're going to get them to touch old books and not allow them to wash their hands," said Bj?rgvinsson, also director of the obsessive compulsive disorders treatment program at the Menninger Clinic. "Depending on the severity of the Obsessive Compulsive Disorder, it usually takes about 12 to 20 sessions for the child to be able to manage their compulsions."
If the child suffers from severe OCD, antidepressants may be prescribed in combination with therapy.
"It's important to use the treatments appropriately to avoid the long-term adverse effects of OCD on the child's development," he said.
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To beat your Obsessive Compulsive Disorder
Stem cells are immature, vigorous cells that mature into any of the hundreds of various body cell types--nerve, blood, heart, muscle, fat, bone, cartilage, etc. They are what turns an embryo into a fetus into a baby into an adult. They have plasticity, meaning they are adaptable and capable of being manipulated into becoming different types of cells.
"After harvesting and concentrating the stem cells in a laboratory, the stem cells and bone marrow are transferred into the damaged ligament or tendon," Herthel says. "They reproduce into normal, healthy tissue, thus improving healing and providing stability to the injured or diseased area. They also reduce inflammation and relieve pain."
It's this type of adaptability that is so promising for treating equine tendons, ligaments, joints, and bones. Often, injuries at these sites cannot repair themselves to a stable, pre-injured status. Adult cells are geared toward maintaining the status quo, possessing a limited capacity for replicating normal cells. Often instead of producing new, healthy, normal tissue after an injury, scar tissue is produced, and scar tissue is often a weaker, inferior tissue, making the recently healed site prone to re-injury.
Explains Rich Redding, DVM, MS, Dipl. ACVS, clinical associate professor of equine surgery, Veterinary Teaching Hospital, North Carolina State University (NCSU), "It's preferable to have everything heal by intrinsic processes in which the normal cells (tenoblasts and tenocytes) that reside in the tendon tissue proliferate and produce normal collagen and matrix to repair the tendon. Unfortunately, many tendon and ligament injuries are so extensive that they must heal by extrinsic pathways in which cells from outside of the tendon/ligament migrate into the damaged structure and predominate the repair process."
In the superficial digital flexor tendon, for example, healing occurs when cells migrate from paratendinous tissue (tissues adjacent to the tendon) into the damaged tendon, filling the defect or injury with granulation tissue (immature collagen and capillaries). "Most of this collagen is a weaker type of collagen," Redding says. "In reality, it is not that the tendon cannot heal--it can. The problem is that the injury heals with a tissue that has different mechanical properties than normal tendon tissue, typically with less elasticity. It is the junction or interface between normal and abnormal tissue that becomes the weak link and the site of re-injury in the future."
But when manipulated stem cells are injected into the injured site, they grow into normal or near-normal tissue.
"The advantage to stem cell therapy is the quality of healing that can be obtained in the implanted tissue," says Christopher Johnson, DVM, MS, Dipl ACVS, of the Equine Division of Woodford Veterinary Clinic, Versailles, Ky. "The goal of stem cell therapy is to improve the quality of the tissue in the injured area during the healing process--as close to normal tissue as possible."
Controversy
Despite the promising outlook for stem cell therapy in horses, the political and media fixation occurring on the human side of stem cell therapy research has lead to a somewhat constipated state in research. In human medicine, stem cell therapy is an emotional issue, swirling around the ethics of using stem cells harvested from embryonic tissues that are frozen, days-old human embryos from fertility clinics. But stem cells reside in--and can be harvested from--a variety of sources, not just from fertilized eggs and embryos. They can be harvested from bone marrow, fat, and umbilical cords--a point that's sometimes lost in the political maelstrom.
In fact, it appears that embryonic tissues are unlikely to be the best source of stem cells, the big reason: Tissue rejection. Because embryonic tissue comes from a donor, it is foreign tissue, and foreign tissue is sometimes rejected by the host patient.
Notes Herthel, "Horses tend to reject embryonic stem cells. (When that happens, the horse experiences swelling, pain, and lack of structural integrity.) In an unpublished study we did in conjunction with the University of Miami, we compared the use of embryonic equine stem cells, bone marrow stem cells, platelet-rich plasma, and a control group in treating ligament tears. The embryonic stem cell treatment gave us extremely rapid healing on ultrasound exam, but within six months, every case exhibited a rejection phenomena. The platelet-rich plasma technique caused significant scarring of the ligaments, while the stem cell bone marrow procedure enhanced healing without causing any scarring."
Cell Sources
The reason fertilized eggs and embryos from early developing fetuses were considered the best source of stem cells is because of their plasticity. Adds Herthel, "Embryonic cells were also considered to be less antigenic--that is, less likely to produce a rejection response--because these cells are so young. But it turns out they are potentially extremely antigenic and not any more plastic than mature stem cells."
Stem cells from the umbilical cord or the blood within the umbilical cord at the time of birth are other potential sources. These cells are extracted, then frozen until needed. Peter Clegg, Vet MB, PhD, Cert EO, Dipl. ECVS, MRCVS, professor at the University of Liverpool, writes, "These may be more efficient stem cells than those we can obtain from bone marrow in the adult horse." ("The Brave New World Of Stem Cell Therapy," Horse & Hound, www.horseandhound.co.uk/care/402/69097.html).
The obvious downside is this is a banking option available only at the time of birth.
Cells harvested from the patient's own bone marrow are showing great promise for several reasons. First, there is no risk of tissue rejection. Second, "many, many studies coming out now are showing that the adult mesenchymal stem cell (from which arises connective tissues of the body, blood vessels, and lymphatic vessels) in the human has tremendous plasticity," says Herthel. "The adult stem cell can become a muscle cell or cardiac cell or tendon cell, etc. It is just as plastic--maybe more so--than embryonic stem cells."
Third, blood marrow contains fibronectin (which aids cell migration through the area of injection) and growth factors (which enhance healing). Finally, this therapy could provide very quick pain relief, as was found on the human side when Herthel's group assisted several human orthopedic surgeons in using this procedure for Achilles tendon tears, patellar tendon (tendon that connects the patella to the tibia), quadriceps tendon (tendon that connects the long quadriceps muscle to the patella), and lateral epicondylitis tendonitis.
"In 2001, Alamo Pintado Equine Medical Center published and presented a scientific paper to the American Association Of Equine Practitioners (AAEP) in San Diego," says Herthel. "This paper reported the results of 100 suspensory injuries that were not treated with bone marrow stem cells and compared the results to 100 horses that had been treated with bone marrow stem cells. In the untreated group, less than 30% went back to work and stayed sound; in the treated group, 80% went back to work and stayed sound for at least one year."
Using a relatively simple surgical procedure, stem cells are extracted from the patient's bone marrow. In previous reports, only a limited number of stem cells, about five to 10, are harvested from a typical bone marrow aspirate, says Redding. "At Vet-Cell in Great Britain, these cells are grown out to sufficient numbers (millions) in a cell culture laboratory, which takes several weeks. This delays the injection until well after the acute stage of injury."
At Herthel's lab, the procedure is a little different. "We do not grow the cells--it takes too long and there is no assurance of what they will do in vivo after being propagated," says Herthel. The latest technique is to concentrate the native stem cell population in bone marrow or fat at the time of surgery, then inject them along with bone marrow into the damaged ligament or tendon."
Fat is another viable source of stem cells. "These cells are harvested from the tail head of the patient horse, then sent to Vet-Stem, the only commercially available laboratory in the United States that does this procedure," says Redding. "There are many types of cells other than stem cells in the sample. Vet-Stem utilizes a proprietary flotation technique to recover the stem cells (and other cells) from the fat sample. The sample is then sent back for use usually in 48 hours. If a large sample of fat is harvested, the extra cells can be frozen for later use."
The short turnaround time allows the cells to be injected soon after the initial injury. A recent research study evaluated tendon healing after treatment with fat-derived stem cells at six weeks using a collagenase induced tendon injury model. This study found that the fat-derived stem cells developed improved overall healing scores over controls. However, more clinical research needs to be performed to assess the optimum use and the effectiveness of fat-derived stem cells in clinical practice.
Best Uses for Stem Cells
Although stem cell therapy is still undergoing exploration, the therapy is available to horse owners who either have the funds or the insurance to pay for the procedure. Vet-Stem lists around 100 veterinarians at their web site who use this technology. "Any vet with a diagnostic ultrasound machine can harvest and inject the stem cells," reports Redding.
At NCSU, veterinarians have used fat-derived stem cells for a variety of tendon and ligament injuries. "Most of the injuries have been discrete core-type defects in the superficial and deep digital flexor tendons and in the suspensory ligament," Redding reports. "We have also used stem cells for a severe collateral ligament injury of the fetlock in a Belgian cross with a very good outcome and in some meniscal injuries of the stifle joint with marginal success."
NCSU researchers hope to establish an on-site laboratory where they can do bone marrow stem cell recovery and culture.
Based on his investigations and other research, Herthel currently employs bone marrow stem cell therapy for several conditions. "We use this technique on suspensory ligaments, check ligaments, superficial and deep flexor tendons, collateral ligaments of the pastern, coffin, fetlock, and femoral tibial ligaments, sacroiliac ligaments, anterior cruciate ligaments, and menisci of the stifle joint," explains Herthel. "We have also used this as an intra-articular treatment on the pastern joints and stifle and hocks, and for osteochondrosis dissecans (OCD) cysts of the pastern joints, medial condyle of the femur, and fetlock joints."
Additionally, Herthel sometimes combines stem cell therapy with HBOT (hyperbaric oxygen therapy implemented via a high-pressure oxygen chamber) and nutritional therapy when treating tendon and ligament injuries.
"A very recent scientific paper about HBOT therapy in people has shown that the number of circulating stem cells in blood can be increased eightfold with HBOT therapy," he explains.
Costs for bone marrow stem cell therapy is about $1,400 to $1,800, including anesthesia and the procedure, says Herthel.
"There are very few riding or performance horses that cannot justify the procedure based on the results and prognosis," he states. "Besides, insurance has paid for all of the horses that had medical insurance. Insurance companies love this, because it saves them millions in loss of use payouts."
Tomorrow
Investigations continue on identifying the best sources for stem cells, accessing the efficacy of stem cell therapies, and uncovering the conditions that are amenable to stem cell therapy.
"The future of this treatment is wide open," Redding says. "Veterinarians are now using stem cells in a variety of clinical conditions beyond tendon and ligament injuries, including severe osteoarthritis of high range motion joints like the stifle, tarsus, and fetlock, and in subchondral bone cysts of the medial femoral condyle of the stifle, fetlock, and pastern. The human literature is filled with basic research utilizing stem cells (both embryonic and adult) in a variety of animal models. Surgically created medial meniscus injuries in goats showed significant improvement in healing when stem cells were injected into the joint when compared to the control joints that did not show any significant response. Cardiac infarction models in calves showed revascularization when cells were injected in the coronary vessels supplying the myocardium; in other words, there may be some application for cardiac disease where it might only need to be injected in the vascular system to supply to the damaged area. Recent reports demonstrated that injection of embryonic stem cells into paralyzed mice (due to spinal cord injury) allowed nerve conduction and the ability to walk.
"However, there needs to be more clinical research to support its use in a variety of injuries and confirm the optimum timeframe for their use," continues Redding. "Prospective clinical trials will be necessary to determine which injuries will benefit from stem cell injection. For example, there may very well be certain injuries that heal sufficiently without stem cell treatment, while others may not show improvement in spite of stem cells."
Herthel is presently studying the benefits of cells by concentrating the native stem cell population of bone marrow and fat with a centrifugation process; this procedure would also allow immediate use after collection of the cells instead of having to waits for days or weeks to begin treatment.
Other new therapies are being evaluated as well, including platelet-rich plasma and ACell. The latter is a matrix material (porcine bladder submucosa) product that is without cells (and thus not a stem cell therapy), Redding states. "ACell therapy has been reported to create considerable pain after injection, which implies it creates an intense inflammatory reaction. It is assumed that this inflammatory reaction may precipitate extrinsic repair. However, this pain response has been reported to be controlled with aggressive anti-inflammatory therapy pre-injection."
Although ACell is currently unavailable in North America due to patent litigation, a company spokesperson said they expect to resume normal business operations in the United States in June or July of this year. Updates concerning the patent litigation are posted at www.Acell.com.
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