An Overview of Regenerative Injections:
Techniques, Products, and Path to Healing
Dr. Dunning believe in harnessing the body’s natural healing capacity to address pain and dysfunction. She recently had the privilege of presenting an overview of regenerative medicine to Athletico Physical Therapy. This session highlighted innovative approaches to healing that offer alternatives or complements to mainstream therapies.
For those who couldn’t attend, please watch the YouTube video, see social media snippets or see summary of key points and insights from the talk here:
What is Regenerative Medicine?
Regenerative medicine focuses on enhancing the body’s own healing processes to repair and regenerate damaged tissues. Unlike conventional treatments that only manage symptoms, regenerative approaches aim to restore structure and function.
Key points:
- Supporting wound healing processes.
- Reduced reliance on pharmaceuticals for pain management.
- Providing minimally invasive alternatives to surgery.
- Offering targeted, precise treatments tailored to individual needs.
- Evidence-based options that promote healing and restore function.
Research continues to refine these therapies, optimizing patient outcomes through advanced techniques and biologics.
Wound Healing Cascade
The foundation of regenerative medicine techniques lies in understanding the wound healing process. Each of the regenerative solutions support structures and healing by optimizing the wound healing pathway.
- Hemostasis (minutes to hours): Stops bleeding through blood clot formation via platelets.
- Inflammation (1 to 3-7 days): Early immune response dominated by Neutrophils, M1 macrophages, and inflammatory cytokines/signaling molecules.
- Proliferation (3-7 days to 3 weeks): Tissue rebuilding facilitated by fibroblasts, growth factors, M2 macrophages, and anti-inflammatory cytokines/signaling molecules.
- Remodeling (weeks, months, to years): Fibroblasts, matrix metalloproteinase (MMPs), and tissue inhibitors of metalloproteinases (TIMPs) also lead in scar maturation and increased tissue strength via collagen reorganization.
By leveraging this natural cycle, regenerative therapies can enhance each stage for optimal tissue repair.
The Importance of Precision
The success of regenerative therapies depends on:
- Patient Factors: Consider age, health status, and regenerative capacity.
- Diagnostics: Complete comprehensive diagnostic work up protocol to ensure the pain generator is addressed. Look at more than just tissue damage on imaging.
- Image Guidance: Use tools like ultrasound and fluoroscopy ensure precise delivery to target tissues.
- Tailored Applications: Use correct techniques, concentrations and solutions tailored to the individual.
Therapies in Interventional Naturopathic Regenerative Medicine
Mainstream Techniques (“Other” Category)
These interventions are commonly utilized in mainstream medicine to manage pain, inflammation, and musculoskeletal issues. While not regenerative, they provide immediate symptom relief or structural support in certain clinical contexts.
Steroids
Local Anesthetics
Function: Steroids are anti-inflammatory agents commonly used to manage pain and inflammation in musculoskeletal conditions.
Types:
- Non-Particulate Steroids: Dissolve quickly and are used for conditions requiring immediate dispersion (e.g., nerve root injections).
- Example: Dexamethasone phosphate
- Particulate Steroids: Provide prolonged anti-inflammatory effects and are used in targeted injections like intra-articular or epidural steroid injections.
- Examples: Methylprednisolone acetate (Depo-Medrol), Triamcinolone acetonide (Kenalog)
Function: Local anesthetics block sodium channels, interrupting pain signaling to provide temporary pain relief during procedures, therapeutic intervention for chronic pain conditions, or provide diagnostic information regarding pain conditions. These are used as a part of a lot of interventional and regenerative injections.
Trigger Point Injections
Target: Trigger points target painful muscles that are thought to arise due to muscle overload, trauma, poor posture, or repetitive strain, which lead to sustained muscle contraction, ischemia, and localized biochemical changes. These perpetuate a pain-spasm-pain cycle.
Mechanism: Injections containing local anesthetics (e.g., lidocaine) may disrupt pain-spasm-pain cycles, mechanical disruption of taut bands, improve perfusion, and reduce localized inflammation. Dextrose may be added to trigger point injections to decrease nerve inflammation.
Hyaluronic Acid
Botox
Function: Hyaluronic acid is a natural component of synovial fluid and cartilage. It acts as a lubricant and shock absorber in joints, reducing pain and improving mobility, especially in osteoarthritis.
Types:
- Low Molecular Weight Hyaluronic Acid:
- High Molecular Weight Hyaluronic Acid:
Applications:
- Knee Osteoarthritis: FDA-approved for viscosupplementation to relieve pain and improve joint function.
- Shoulder, Hip, Ankle, and other Joints Arthritis (Off-Label): Used to reduce pain and restore mobility in other synovial joints.
Function: Botox is a neurotoxin that temporarily blocks the release of acetylcholine at the neuromuscular junction. This reduces muscle spasticity and tension, making it particularly effective for conditions involving overactive muscles or chronic pain.
Applications:
- Chronic Migraine: FDA-approved for reducing the frequency of headaches in patients with 15 or more headache days per month.
- Muscle Spasticity: Effective in treating conditions such as cervical dystonia, spasticity after stroke, or cerebral palsy.
- Myofascial Pain Syndrome: Helps relieve tightness in trigger points when conventional therapies are not sufficient.
Dextrose Based Therapies
Historically, dextrose-based therapies were classified into three concentration-based ranges—anti-inflammatory (<10%), inflammatory (10–30%), and sclerotic (>30%)—to categorize their effects. These classifications were thought to align with specific mechanisms of action, such as reducing inflammation, stimulating tissue repair, or inducing scar tissue formation. However, recent research and advancements in regenerative medicine have shifted the focus to cell-mediated mechanisms that modulate the wound healing cascade more dynamically.
Old Model
Anti-inflammatory (<10%)
Inflammatory (10–30%)
Sclerotic (>30%)
Function: Targets nerves to reduce neurogenic inflammation and pain signals. Can be applied with different techniques perineurial, nerve hydrodissections, and fascial plane hydrodissections
Function: Stimulates tissue repair through controlled inflammation, addressing ligament laxity and joint instability.
Function: High-concentration dextrose solutions are used to break down cystic formations and restore normal function.
New Model
Emerging research now emphasizes that dextrose acts on a cellular and biochemical level to influence the wound healing cascade rather than working solely through concentration-dependent effects. This aligns with regenerative medicine’s growing focus on modulating the body’s healing response instead of relying on direct mechanical or inflammatory actions. This new understanding enables practitioners to apply dextrose more effectively across a range of conditions, from nerve pain and joint instability to chronic soft tissue injuries, with the goal of facilitating long-term repair and functional recovery. Different applications such as perineural, nerve hydrodissection, and fascial plane hydrodissection are still techniques that can be used with the lower dose dextrose concentrations.
Key insights include:
- Cellular Modulation: Dextrose influences fibroblasts, macrophages, and growth factors to promote tissue remodeling and repair. It does so by creating a pro-repair microenvironment rather than inducing inflammation or scarring. In perineural injection therapy, low-dose dextrose restores nerve health by resetting abnormal firing rates and reducing neurogenic inflammation, mediated by glucose-sensitive cell pathways.
- Macrophage Polarization: Dextrose can modulate macrophage behavior, transitioning them from the pro-inflammatory M1 phenotype to the repair-oriented M2 phenotype. This supports wound healing by reducing prolonged inflammation and facilitating tissue remodeling.
- Stimulation of Growth Factors: Dextrose stimulates the production of growth factors such as VEGF (vascular endothelial growth factor) and PDGF (platelet-derived growth factor), promoting angiogenesis (new blood vessel formation) and collagen synthesis.
- Matrix Remodeling: Rather than inducing scarring, dextrose supports balanced remodeling of the extracellular matrix (ECM), enhancing tissue elasticity and resilience.
Advanced Orthobiologics
Autologous vs. Allogeneic Therapies
A critical distinction in regenerative medicine lies in the source of biologic materials:
Autologous Therapies
Allogenic Therapies
Derived from the patient’s own body.
- Plasma: Platelet-Rich Plasma (PRP)-Contains concentrated platelets and growth factors to stimulate healing and tissue repair. Leukocyte-Rich PRP-Ideal for acute injuries with inflammatory processes. Leukocyte-Poor PRP: Designed for chronic conditions where inflammation needs to be minimized. Platelet-Poor Plasma (PPP)-Contains lower levels of growth factors and cytokines but can still offer mild repair and anti-inflammatory effects. Alpha-2-Macroglobulin (A2M): Protects cartilage by inhibiting enzymes that break down connective tissue. Promotes anti-inflammatory effects by binding and neutralizing harmful cytokines.
- Bone Marrow Aspirate Concentrate (BMAC): Harvested from the iliac crest and rich in growth factors and reparative elements. In normal human physiology, bone marrow can supports bone repair, osteogenesis, and soft tissue healing. Research show that it loses it cellular content with age.
- Micronized Fat Therapy: Adipose tissue is harvested via lipo-aspiration, resized mechanically, and reinjected. Advantages include high levels of structural extracellular matrix components and has show to sustain cellular content with age.
Derived from donor source.
Examples
- Exosomes: A concentrated A-cellular products of secreted molecules like microRNAs, proteins, and lipids that are released from mesenchymal stem cells.
- Perinatal Tissues: Derived from Wharton’s jelly, amniotic fluid, placenta, or around birth tissues.
- Adipose-Derived Stromal Vascular Fraction (SVF): Processed from fat tissue to isolate components from connective tissue.
Regulatory Considerations
In the United States, the Food and Drug Administration (FDA) provides guidelines in regenerative medicine products under specific guidelines:
Minimal Manipulation and Homologous Use: The FDA distinguishes between products based on the degree of manipulation and their intended use. Products that are minimally manipulated and intended for homologous use (performing the same basic function in the recipient as in the donor) may be subject to less stringent regulatory requirements.
Investigational New Drug (IND) Applications: For therapies that do not meet criteria for minimal manipulation and homologous use, an IND application may be required to conduct clinical trials, ensuring safety and efficacy before broader clinical application.
Terminology and Clinical Application: It’s important to note that the term “stem cells” is often associated with a range of cell-based therapies. This term is reserved for clinical trials even though our basic understanding in physiology locates stem cells to be rich in perinatal, bone marrow, and fat tissues. However, the FDA has specific regulations regarding the use of stem cells, particularly in clinical settings.
Explore Your Options
Dr. Dunning offers a comprehensive range of regenerative treatments tailored to your needs. Whether you’re recovering from an injury or managing chronic pain, she is here to guide you toward lasting healing and recovery.
Learn more and schedule a free 15-minute consultation today.