Top 10 Questions to Ask a Stem Cell Clinic

By Chris Centeno, MD /

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top 10 questions to ask a stem cell clinic: questions for orthopedic stem cell providers

Orthopedic stem cell providers are not all created equal. When making the decision to put all of your trust into a stem cell clinic and physician, it’s important that you know the right questions to ask—and just as important that you know whether or not you’re getting the right answers. Our top 10 questions to ask a stem cell clinic will help you scope out – based on questions orthopedic stem cell providers should be able to answer – at least what type of clinic has the greatest chance of accomplishing what you’re paying them to do.

1. How much experience do you have?

Experience is everything in medicine: the more a surgeon or physician has practiced a particular skill, the better the outcome and the fewer the complications. For most surgical procedures, for example, surgeons will consider themselves competent after 20–50 procedures. They won’t usually consider themselves an expert unless they’ve done a procedure two hundred times or more.

Procedures that use stem cells to treat arthritis are no different. Ask your physician how many stem cell based procedures of the type you need he or she has done.

Bait and Switch: Physicians at some clinics will talk about the number of procedures they’ve done that involve PRP (platelet rich plasma); make sure your provider gives you the specific answer for stem cell based treatments. We’ve also seen new providers list the total number of surgical procedures they have performed (that didn’t involve stem cells).

2. What kind of data do you collect and report?

Where’s the data? Stem cell treatments for arthritis are pretty new: most doctors classify them as “investigational care,” meaning that the techniques are not yet fully understood. That’s not something that should scare you as a patient—after all these years, we still don’t fully understand how aspirin works in the body—but it does mean that data should be collected by the clinic at all times. The data collected should go beyond a simple phone call after the procedure. Providers should want you to complete a questionnaire that will ask you about your pain level before and after the procedure, how well you can use the affected joint now that the procedure is finished, and whether or not there were any complications from the procedure.

Ask what information the clinic collects and where this information is located on their web site. Investigational care results should be indexed in a registry, which is an organized place to collect data on that specific procedure. This registry allows other physicians to review the data and allows the medical community as a whole to improve its techniques and the practice of medicine.

Also, ask if there are any publications in medical journals regarding this specific procedure. This is an area to be careful with as some less-scrupulous clinics may “borrow” the studies of other procedures that aren’t actually the same as the procedure they want to do on you, such as using research on bone marrow stem cells instead of the fat stem cells the clinic is actually using. If there isn’t a large amount of data for your particular procedure yet, ask where you can read about their previous history with this procedure—both their successes and their failures. Clinics that are involved with investigational care should post information from their registry about all of their patients, even those who didn’t respond to the treatment.

In summary, it all comes down to one simple issue. Where is the data that this clinic has collected on this specific procedure on their website? Where is the patient infographic that shows results? Where are the publications? By the way, you can find ours under the research tab above.

3. What’s your physician specialty?

Physician specialty matters. As a musculoskeletal specialist, I have in the past used Botox to treat a medical condition called dystonia. Sometimes, one of my female patients will ask me to perform a cosmetic Botox treatment. I probably could, but I won’t because I’m not a cosmetic dermatologist or plastic surgeon, which means I don’t have the specialized training these physicians go through to achieve the best results for their patients.

Medical specialties exist for a reason. I have thousands of hours of specific training in nonoperative orthopedics, and while I could certainly deliver a baby in an emergency, that’s not my specialty. If something goes wrong with the delivery or there are complications, I would certainly do the best I can, but I don’t have the specific training that an OB-GYN has. By the same token, while your plastic surgeon or family care physician has thousands of hours of specific training in his or her specialty, this physician doesn’t have the specific training or experience with orthopedic procedures in general or with orthopedic stem cell procedures specifically.

Specific training means better results. Ask your physician if he or she is board-certified in a specialty that is specifically trained to perform injection-based care into joints. A board-certified physician who specializes in sports medicine, physical medicine, or interventional pain treatment has the specialized training and experience to do these procedures correctly. While some orthopedic surgeons have undergone extra injection-based training using guidance to perform these procedures, most have not. You would think that a surgeon should be able to perform a complex injection, but many still perform these procedures blind. So if an orthopedic surgeon is performing the injection, make sure that he or she has extensive training in guided injections under ultrasound and/or fluoroscopy.

4. What cell source are you using?

Cell source is important. Stem cells are located in just about every part of our bodies, but not all stem cells are the same. The specific type of stem cells that are used to treat knees, hips, shoulders, and ankles can be obtained from several sources—the most common sources are adipose tissue (the layer of fat we all have beneath our skin), and bone marrow. For some issues, such as mild joint arthritis or a partial rotator cuff tear, the platelets found in blood can help, but for larger areas of involvement, the platelets in blood are usually not sufficient.

This leaves bone marrow and adipose tissue as possible stem cell sources for joints and tissues that are more degenerated Adipose stem cells may be able to help in orthopedic conditions, but in head-to-head studies with bone marrow stem cells, they are less able to repair joint tissue like cartilage. Bone marrow is the best source for stem cells to be used to help cartilage health.

“Amniotic stem cells” have become an epic case of widespread consumer fraud. The problem? The vials of amniotic, placental, or fetal tissues being used by clinics offering this type of stem cell treatment don’t actually contain any living cells (companies manufacturing these off-the-shelf products are required to actively kill all of the cells in them with gamma irradiation). That, however, hasn’t stopped unscrupulous or less-than-knowledgeable clinics from claiming that the patient is getting injected with millions of live stem cells. Hence, any clinic claiming to use amniotic stem cells to treat orthopedic conditions should be avoided as they’re really injecting a bunch of dead baby tissue.

When you talk with your provider, ask the physician where he or she harvests the stem cells from. If the physician only takes stem cells from fat (adipose stem cells), then the clinic you are in is not primarily focused on orthopedic issues or is not staying up to date with the science behind the procedures. There have been some less-reputable plastic surgery and age-management clinics that are starting to offer stem cell treatments for orthopedic issues. These clinics only harvest stem cells from adipose because they aren’t trained to perform stem cell harvesting from bone marrow.

5. What harvesting technique are you using?

Harvesting technique is critical. Stem cells are removed from the body, or “harvested,” in several different ways. The stem cells that are the most useful for orthopedic care are found in bone marrow. The methods used to harvest these cells are critical to the success of the procedure. For fat stem cells, physicians use liposuction to harvest the stem cells. The harvesting of stem cells from bone marrow requires a technique called bone marrow aspiration.

Bone marrow aspiration is a procedure that requires a great deal of experience. Because bone marrow is the richest source for stem cells that are the most useful for orthopedic issues, it is important to actually harvest bone marrow, yet this is difficult without some form of imaging guidance. If your physician does not use some sort of imaging to guide his or her work (either fluoroscopy or ultrasound), there is a significant risk that he or she will aspirate blood with no stem cells instead of bone marrow with stem cells. Additionally, if a physician only harvests from a single spot (rather than multiple sites in the bone), the physician runs the risk of getting fewer stem cells, even if he or she does get bone marrow aspirate.

Also make sure that you ask if the clinic uses a cell biology lab or a tool on-site to confirm that it has harvested actual stem cells (see number 6 for more).

6. Do you count the cell dose in the sample?

Dose in medicine is key. In stem cell therapy, the issue of whether you’re getting enough cells to maximize the chance of a successful treatment is an epic fail on the part of most clinics. 

After stem cells are harvested, they are processed to remove the less-useful tissues and concentrate the fraction containing stem cells. They may also be cultured, which means that the stem cells are placed in an environment that encourages them to multiply.

We’ve seen a lot of clinics that offer stem cell treatments where the cells are processed in bedside kits—small machines that centrifuge, or shake, the tissue, to isolate a stem cell rich fraction. The vast majority of clinics that use these bedside machines have no idea how much of what they inject back into you is actually stem cells because they can’t count the cell content of the samples they’re injecting.

As an example, based on our dosing research, only about one in three to one in four older patients have enough stem cells to inject both knees. Since we count the cells, we know who doesn’t have enough. In addition, since we use sophisticated stem cell harvest techniques, we can adjust that procedure to obtain more cells. Compare that to a clinic that has no idea how many cells you have or how many you need. Are you willing to spend big bucks on a treatment and then flip a coin as to whether you had enough cells to treat all of your problems?

7. How do you make sure the stem cells are placed where they’re needed most?

The stem cells must hit the bull’s-eye. Your physician must know how to accurately and precisely inject your stem cells into the actual damaged or degenerated area to be optimally effective. Even being off by as little as an eighth of an inch may make the difference between a successful outcome or continued pain and dysfunction of the joint.

Make sure your provider will use some form of imaging (fluoroscopy or ultrasound) to guide the injection. Run away if the clinic is using a “blind” injection technique. In addition, make sure you know the difference between highly precise injections under guidance and “in the neighborhood” is good enough. Or as I call it, the sharpshooter vs. the shotgun approach.

Many clinics that do use guidance will place the cells anywhere they can easily reach in the joint (the shotgun). Other clinics will have advanced training on how to place cells in a specific structure (the marksman or sharpshooter). For example, in a shoulder, the shotgun approach is placing cells in the back part of the main joint under ultrasound or the front using fluoroscopy. However, the marksman has the advanced training using either or both technologies to place cells in the superior labrum where the biceps attaches.

Why pay for a blind injection or even a shotgun approach when you can have your cells precisely placed where they’re needed most?

8. Are you using medicines or common additives that kill stem cells?

Some common medications and additives can kill stem cells. These come in three flavors: anesthetics, steroids, and other medications.

Many providers use local anesthetics to numb the area. However, the most common local anesthetics kill stem cells. Ask your provider if the medicines he or she is using come in contact with the stem cells. Sometimes this is unavoidable, but there’s only one anesthetic that’s safe for cells, an obscure OB-GYN anesthetic called ropivicaine (that’s not commonly found outside of the baby-delivery area). If your provider is using lidocaine or bupivacaine/Marcaine to numb the joint or other area, that’s a problem. It also shows a lack of knowledge and sophistication with the procedure that’s problematic.

Steroid injections into joints are commonplace, but they regrettably kill cartilage and other cells when injected in the massive doses that are commonly used. In the same way that steroid shots kill all local cells, they will also kill stem cells. There should be at least 6–12 weeks of time separating a steroid injection from a stem cell injection. In addition, if the doctor does more steroid injections in his or her practice than PRP or stem cell injections, you may want to look elsewhere as that provider is sacrificing patient outcome for the convenience of a procedure that an insurer will cover. Finally, while milligram-dose steroid injections kill cells, specially compounded nanogram doses (one million times less), can help cells. However, outside of a few providers, 99.999% of doctors use the high-dose variety that kills cells dead.

Lastly, many prescription medications have negative effects on stem cells. We’ve developed a list based on years of observation on which meds make it harder for stem cells to propagate in culture. If a physician has no experience growing stem cells, he or she has no list of medications that you shouldn’t take. This is despite the issue that staying on a prohibited medication likely reduces your chance of a successful procedure.

9. How sophisticated is your cell lab?

Level of lab sophistication matters. Most physicians’ offices don’t have an on-site lab, but even if they do, not all labs are equal. A dedicated cell biology lab will have equipment that a regular doctor’s office simply does not need because this equipment is absolutely vital to giving you the best possible outcome.

The first question to ask about the clinic’s cell lab is if they use an “open” or “closed” system. A “closed” system keeps tissue samples in a germ-free environment, inside a clean hood. An “open” system exposes tissue samples to open air, where they are susceptible to being contaminated by bacteria in the air.

A dedicated cell biology lab will also have devices that allow doctors to count cells. Cell biology labs also use air quality checks, sterility checks of clean areas, and protective gear for the technicians in order to give the highest possible assurance that your stem cells will be protected from contamination.

10. What’s your success rate, and am I a good fit?

Avoid hype about lack of complications, too-good-to-be-true success rates, and candidacy.

Even the best and most successful clinics have patients who do not respond as well as can be hoped, and even the most careful physicians have patients who develop complications. Unfortunately, in the field of medicine, these things happen. Physicians do absolutely everything in their power to minimize these risks as much as possible, and some aspects of patient care are beyond a physician’s control.

Physicians or clinics that tell you they have a 100% success rate or close to it are, frankly, lying or rigging the numbers. Even the best stem cell clinics have a success and failure rate. Ask your stem cell provider what his or her success rate is for the stem cell procedure you’re considering. If the provider ’s answer includes a frank discussion of the chances that the procedure will fail, then you have a physician who is being honest.

Every honest physician should also be able to tell you whether or not the procedure he or she is offering is a good fit for your particular condition. Every patient is not a good candidate for every procedure. Ask the question, “What percentage of patients have you turned away or told that they were a poor candidate for this procedure?” If you get a blank stare or silence or if you believe the only test the physician uses to evaluate you for a stem cell procedure is your credit rating, run out of that office as fast as you can, and don’t look back. In addition, ask what your candidacy rating is based on.  Meaning does the clinic use its own registry data to see who is a good or bad candidate? Also ask where can you find that data.

Knowing the top 10 questions to ask a stem cell clinic can make the difference between a successful and an unsuccessful treatment. There are qualified orthopedic stem cell providers out there, and unqualified ones. Hopefully knowing what questions orthopedic stem cells providers should be able to answer will help you find the ones that can actually help you.

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24 thoughts on “Top 10 Questions to Ask a Stem Cell Clinic

  1. Joanne Hartman

    this is a wonderful article. Thank you for posting this. I am an RN and have had stem cell surgery for my spine. It was unsuccessful the first time since the orthopedic doctor did only C7. Unfortunately, I needed to have the procedure done under fluoroscopy and needed C1-C6. I am finally feeling strong again after a lengthy recovery. The first stem cell surgery was September 28th and second using fluoro. was February 16th. I finally feel terrific. Again, thank you for posting this article

    1. Regenexx Team

      Joanne,
      So glad you enjoyed it, and so great to hear you are feeling terrific! Spine procedures should never be done without fluoroscopy guidance, so thankful the second go was!

  2. Ernestine Mullin

    This is an absolute excellent article, written by one who not only instructs, but also, teaches – his students AND his public!! Many kudos to you, Dr. Centeno!! … a true professional….

    Kind regards,

    Ernestine Mullin
    Regenexx Advocate

    1. Regenexx Team

      Ernestine,
      Thanks…you are a true Regenexx Advocate!

  3. Larry Roelofs

    I had a stem cell treatment done to my right ankle on Feb 5,2016 by Dr. Lox of another clinic. He used the adipose stem cells from my lower back side. After waiting about 45 minutes for him to isolate the stem cells( I have no idea what harvesting technique he used), he was ready to inject the stem cells into my right ankle joint. He did not use any fluoroscopy or ultrasound technique to guide the stem cells into my ankle. He simply injected the stem cells into my ankle joint. He said after two months I should see an improvement in my right ankle joint pain. I’m afraid its not working because I have the same amount of pain as before the procedure. I went to Dr. Lox, due to the cheaper cost, but now I am afraid I wasted a lot of money and am very upset that I will live the rest of my live with the pain. I know I have damage to the cartilage in the ankle from previous orthopedic surgeons who have X-rayed my ankle. One surgeon wanted to replace my ankle, but that scares me, so I had all my hopes on stem cell. Your articles are very informative and I’m afraid I fell prey to those clinics you warn about.

    1. Regenexx Team

      Larry,
      You’ve already stated the issues yourself, very well. Sounds like the procedure was one month ago…lets hope for the best! http://newregenortho.com/

  4. William Wolfmeyer

    Can you recommend any Dr. St Louis area?

    1. Regenexx Team

      William,
      Not St. Louis, but there are 5 approximately equidistant to St. Louis: http://www.regenexx.com/find-a-physician/

  5. Wally

    I have seen nothing for shoulder bone on bone conditions. Is this something stem cell can improve?

    1. Regenexx Team

      Wally,
      Yes, with the right kind of stem cell treatment: http://www.regenexx.com/the-regenexx-procedures/shoulder-surgery-alternative/

  6. Cheryl

    How accessible is it to Canadians? What is the cost and is any of the costs recoverable? I am a 57 yo female facing a knee replacement for OA.

    1. Regenexx Team

      Cheryl,
      We don’t have any Regenexx providers in Canada, however we have many Canadians traveling to our Providers here:http://www.regenexx.com/find-a-physician/ http://www.regenexx.com/the-regenexx-procedures/knee-surgery-alternative/ I will inquire whether Canadian citizens have recovered any of the costs. Here the exams and certain other things are billable to insurance, the procedures themselves are not covered. If you would like to find out if you’re a good Candidate for a Regenexx Procedure, please fill out the Candidate form. The physician you speak to would have a good idea about cost, once the Candidacy evaluation is done.

  7. Judith Glick-Ehrenthal

    Can you provide information on hip procedures more frequently of all ages?

  8. Sonya Liebendorfer

    Can you help me if my hip space is “obliterated” on xray?

    1. Regenexx Team

      Sonya,
      We’d be glad to take a look at the “obliterated” X-ray. Please fill out the Candidate form on this page which also goes over hip conditions treated: http://www.regenexx.com/the-regenexx-procedures/hip-surgery/ Doing so will allow you to upload that and other films and set up a chat to see if you’d be a good candidate for a Regenexx Procedure, and in your case, what type of Regenexx Procedure would likely be necessary.

  9. Sharon

    Where can I find the answers to these questions re: a specific Regenexx provider? What requirements do you have to keep Regenexx providers and their clinics current and in good standing?

    1. Regenexx Team

      Sharon,
      Are you looking for a Regenexx Provider in a particular state or part of the country? This link will take you to the individual Regenexx Provider’s websites: http://www.regenexx.com/find-a-physician/ All of the Regenexx Providers have gone through the most rigorous selection process, training, and ongoing training that exists in the field. Please see: http://www.regenexx.com/blog/our-network-providers-are-highly-trained/ and http://www.regenexx.com/blog/regenexx-network-annual-conference/ and https://regenexx.com/blog/building-a-network-of-quality-physicians-using-stem-cells/

  10. Denis

    Approximately how many stem cell procedures has Dr. Centeno performed, especially as compared to others in the Regenexx network? From what I’ve read, you screen, choose, and train your network providers well, but I’m wondering would it be worth it (for those not in Colorado) to absorb the cost of travel/lodging etc. to see the “main doctor” who undoubtedly has reviewed, performed, and taught many more of these procedures than others in your network (and elsewhere). There may be factors involved in this that can’t be answered in a quick blog post, so if you can’t answer this here, that’s OK. Thank you for all the information that you do provide…

    1. Regenexx Team

      Dr. Centeno, and his partner Dr. Schultz have obviously performed more Regenexx procedures than any of the other doctors. That said, a decision was made early on to create a network of physicians who could deliver the same type of care based on the research done in Colorado, in as many locations as they could find doctors with the very high level skillset that would be needed to train….as they could not treat everyone themselves. That has become the Regenexx network. If for you it’s important to come to Colorado to be treated by one the 5 doctors at the Centeno Schultz clinic, we’d be glad to make that happen.

  11. Anne Smith

    Dear Dr. Centeno – I read your interview on Bioinformant and was very interested to learn about your hypothesis that in ACL repair, the natural synovial invagination acts as a scaffold for the stem cells – makes sense. Do you think that for larger retractions, seeding cells onto an implanted artificial scaffold might be an option?

    Another question regarding the FDA guidelines on non-homologous use – would the Regenexx system be allowed if this became law? Or would it need to be approved through an IND application?

    1. Chris Centeno Post author

      Yes, larger retractions may benefit from an implanted or injected scaffold. Given that bone marrow stem cells are used in a homologous way to treat cartilage and ligament (i.e. micro fracture is commonly performed for these problems), my guess is no.

  12. stef

    Canadian government reimburse through the income tax return what is not available in canada. I have been reimburse every time i have gone to new jersey for a regenexx treatment.

    1. Regenexx Team

      Stef,
      That is great news! Thank you for sharing it; many people have inquired about Canadian coverage on several different platforms.

Chris Centeno, MD

Regenexx Founder

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications.
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