Regenerative Medicine
Devices used in regenerative medicine are rapidly evolving in veterinary medicine. These innovations use orthobiologics — therapies developed from the horse’s own blood, cells, or tissues — to promote healing. That has added some stall-side management options for veterinarians and their clients, the horse owners and managers who care for equine athletes. But what do regenerative medicine devices (RMDs) like platelet-rich plasma therapy and autologous protein solutions involve and how do they help? How do they differ from other treatments, and can they be used in conjunction with other therapies?
We sat down with equine surgeon Dr. Liberty Getman, who also is an equine technical services veterinarian with the largest standalone global veterinary pharmaceutical company, Zoetis, to ask these questions and find out more about orthobiologics and their use. Dr. Getman calls orthobiologic therapies, also called regenerative medicine devices, “a game-changer” in veterinary medicine but notes that they are more helpful for some equine problems than others.
US Equestrian: What are the benefits of orthobiologics compared to more traditional treatments people might be more familiar with?
Dr. Getman: In my experience, we’re trying to give a horse the same amount of pain relief that they would get from a more traditional treatment like a steroid. But the benefit to using an orthobiologic is that we know that, over time with repeated use, steroids actually cause further cartilage breakdown and joint destruction. So what we’re really trying to do is put a product in the joint that not only is going to relieve the horse’s pain, but also help to heal whatever’s going on in that joint and not contribute to further joint damage.
Orthobiologics is kind of an umbrella term, but the ones that we’re using specifically are going to help decrease the inflammation in the joints, heal some of the damage that’s already there, and hopefully prevent any arthritis from progressing at a faster pace.
How do they work?
The substances these regenerative medicine devices produce, or at least in the three that Zoetis has, are growth factors, which promote healing, and anti-inflammatory proteins, which decrease inflammation1,2. All of these types of proteins are
found in the horse’s blood. We take those proteins — the good, healing proteins and the anti-inflammatory proteins — out of your horse’s blood, concentrate them, and then put them back into your horse’s joints. They’re not drugs; they’re not classified as drugs by the Food and Drug Administration. They’re proteins from your horse’s own body and blood that are meant to help heal the joint, decrease inflammation1,2, and slow the progression of arthritis.
Are there horses for whom that kind of orthobiologic therapy might not be appropriate? I think probably as many as 80% of the lameness cases in performance horses that I see could benefit from one of these regenerative therapies. The cases that don’t see as much benefit are those that already have severe joint damage. So if they have severe bone-on-bone osteoarthritis or are very lame, we know at that point, that’s probably a lost cause in that joint; nothing can regrow cartilage once it’s gone.
These therapies work for just about every type of lameness and most degrees of lameness until you get to those very, very severe cases and those end-stage joints.
Is it safe to give a horse fairly regular therapy with an orthobiologic like a Pro-Stride® APS device if, say, they are older or have some history of needing joint injections with steroids for maintenance?
It would be my preference to use a Pro-Stride APS device rather than steroids for maintenance type injections, because, although steroids do provide pain relief, repeated steroid use in a joint over time is going to cause further cartilage breakdown. When those were the only products we had to treat achy or painful joints, it was appropriate to use them. But I think now we also have products that aren’t going to contribute to the joint damage, and it’s our job as veterinarians and horse owners to do what’s best for the horse and what’s best for the joint in a specific case. In general, a maintenance schedule with something like Pro-Stride is going to be similar to a maintenance schedule with steroid injections. Every horse is different, depending on their degree of lameness, and the disease that’s in that joint. But I would say, on average, I’ve noticed in my personal practice that you’re going to get about the same amount of pain relief in terms of time, and maybe a little bit longer, with Pro-Stride than you do with steroids. I certainly have clients who felt like the effects lasted longer. But the biggest thing for me is this, especially if you have a horse who’s a little bit younger or middle-aged: when you inject the horse’s hocks with steroids the first time, you might get a year out of that, but the next time, it might be nine months.
"They're proteins from your horse's own body and blood... to help heal the joint decrease inflammation, and slow the progression of arthritis"
And the next time it might be six months. So you’d get progressively shorter action out of a steroid injection because the joint is continuing to break down, and the steroids are speeding that up. Every horse is different. And with as with anything, the more advanced the disease gets, the harder it is to find any sort of silver bullet for it. But what I do in a lot of those cases who have more advanced arthritis is, not to say that I would never use steroids in them, but instead, to prescribe steroids one year and Pro-Stride the next in an alternating fashion. Another thing to consider is that, as these horses get older, some of them are more prone to some metabolic conditions. And we know that when you put steroids in horses that have or are at risk for metabolic disease or insulin resistance, steroids can increase their risk of developing laminitis. Pro-Stride won’t do that. So with any horses that are getting a little bit on the older side, I do strongly suggest the clients to go with Pro-Stride.
How much difference is there in terms of cost to the horse owner?
I can’t really give you any exact numbers, because obviously it varies from clinic to clinic and from one part of the country to another. But I will say, these therapies aren’t exorbitantly expensive. I think most people’s fear is that, if you’re spending $750 on hock injections now, is the regenerative medicine device going to be more like $3,000? And the short answer is "no." I would encourage people to reach out to their veterinarians and see what their price point is. But I would say, depending on the number of joints you’re
doing and the size of the joint that you’re doing, we’re talking a few hundred dollars’ difference, depending on how many joints you’re treating.
What kind of workload can a horse perform after an RMD treatment?
If it’s a routine joint injection, then I’m going to have you get back on your horse in two or three days and do some light work for a couple of days before returning to full work again. Every veterinarian is going to have their own preference, but I would say two or three days is what most people are recommending for a joint. If it’s a soft tissue injury, that’s going to depend on the extent and type of injury that the horse has. That’s usually going to be a longer process. In general, my clients can expect the same follow up protocol they have with steroid injec tions, with the caveat that you need to give the injection a solid two to three weeks before you’re going to see the full effect
Why does it take longer to see the positive effects of an RMD like Pro Stride than it does to see those effects from steroid injections?
I always tell people that it’s going to be about two or three weeks before they see the full effect of a Pro-Stride APS device therapy, but an important point to make is that even though it might take that amount of time to see the full effect, you can still put your horse back to work in the same timeframe that you would with a steroid injection. Most of my horses got about three days off with a steroid injection and also get about three days off with Pro-Stride. That’s also going to be clinician-dependent. In general, you don’t need to give your horse more time off, but it does take longer for Pro-Stride to have its full effect. The reason is because it works on cell signaling; it’s relying on those proteins to go in and bind to differ ent receptors. That’s a slower system than simply pouring water on a fire, which is more how the steroids operate. But I look at it this way; if you put out the fire in front of you and the forest is still burning behind you, you’re not going to be able to pour enough water to put the whole fire out. Pro-Stride puts water on the fire in front of you but also turns off the bigger fire.
What should the horse owner know about the procedure and how it’s done? And should the horse be sedated?
Yes, the horse should be sedated. There will be a blood draw, because these proteins are found in your horse’s blood — that’s where we get them from. It’s just a simple sterile surgical prep on your horse’s jugular vein. The veterinarian will pull 60cc of blood sterilely, so not a lot. And then that will get processed with the device in a two step process using a centrifuge. While that’s happening, it’s just going to be like any other joint injection from there on: the horse will be sedated, the joints will have a sterile prep put on them, and the solution will be injected sterilely.
We’ve talked a lot about using orthobiologics to manage arthritis in joints, but can they also help soft-tissue injuries?
Orthobiologics are certainly the preferred method of therapy for soft-tissue injuries. The Restigen® platelet-rich plasma (PRP) device has been intensively studied in soft-tissue injuries, and PRP would be my preference for those. However, there is some emerging research looking at Pro-Stride in soft-tissue injuries, and it seems to work well, too. So you can use either, but the most extensive research so far has been behind using Restigen PRP for soft-tissue injuries3,4. We also use CenTrate®, a bone marrow aspirate (BMA) device, for soft-tissue inju ries or for a soft-tissue structure that attaches to a bone — so a tendon or a ligament where it’s attaching to bone. The difference between CenTrate BMA and Pro-Stride or Restigen is that, in addition to having the same healing growth factors and anti inflammatory proteins, it also has stem cells in it as well. These are live cells, and you get them from the bone marrow. It’s a little bit of a different process: you take a bone marrow aspirate from the horse’s sternum to get these. Typically, I use CenTrate on these kinds of injuries that I know are going to be hard to get to heal, like chronic hind-limb proximal suspensory issues, meniscal problems in the stifle —issues that we know are difficult to heal. That’s where bone marrow concentrate seems to show the most promise.
We’ve seen so much change in veterinary medicine in the last 20 years or so. As a veterinarian, how much difference do these new orthobiologic therapies make to your ability to manage equine injuries?
They’ve been a game-changer, literally one of the most exciting advancements in treatment that we’ve had in veterinary medicine. As a human who has her own sports injuries, I can’t wait until the human side catches up with what we’re able to do for our equine athletes. Based on my experiences, I believe regenerative medicine has dramatically decreased healing times, has improved the heal ing in our soft tissue structures, and has allowed these structures to heal with less scar tissue, which can decrease their chance of re-injury down the road. It’s been so much healthier for the joints than repeated steroid use. So we’re keeping these joints healthier for longer, which is keeping our horses in work for longer.