Understanding Inflammation: The Good, the Bad, and the Ugly

By Chris Centeno, MD /

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undertsanding inflammation

Do you have chronic knee inflammation, or inflammation of other joints? Most patients and even physicians have a hard time understanding inflammation and the concepts behind it.  First, the word is derived from the Latin “inflammo” which means “I ignite”. So the word’s origins have to do with fire-makes sense since inflammation is the body’s fire. There are three different types of inflammation-the normal healing kind (the good), the abnormal healing kind (the bad), and chronic inflammation (the ugly). It’s differentiating these three kinds of inflammation where most patients and physicians get completely confused. To try and cut through that confusion, let’s look at chronic knee inflammation in terms of a construction site.

First, without inflammation, injuries would never heal. So healing inflammation is good. In this type, the body removes cellular debris and brings cells to the area to orchestrate healing. If you think of the injured area (i.e. a sprained ankle) as one big construction site, this type of inflammation represents all of the essential components of remodeling a house-the call to the general contractor (signaling by damaged cells with cytokines), demolition of the area to be repaired and removal of debris (accomplished by many cells including macrophages), delivery of supplies (increased blood flow [redness], stem cells and other cells recruited to the area), supervision of the new construction by the general contractor (accomplished by stem cells and a complex dance of cell to cell communications), and final building of the new structure (the stem cells and other local progentors differentiate [read turn into] the needed bricks and mortar, two by fours, etc…).

The last 10 years the news headlines have been abuzz about inflammation being bad, so many patients and physicians don’t differentiate this type of good healing inflammation from the bad type (more on that one in a minute). For example, blocking healing inflammation with powerful anti-inflammatory drugs after injury is likely not a good idea, yet we still see the mantra R.I.C.E. (Rest-Ice-Compression-Elevation). Where did this come from? In rare instances, severe inflammation can occur in a confined space and cause a compartment syndrome (causing the blood vessels and nerves to be damaged). This is very rare, so while looking for this problem is very important, designing a mantra for the other 99.999% of healing inflammation based on the avoidance of compartment syndrome by reducing natural swelling from acute injury isn’t smart. This is in fact where we got our concept of taking anti-inflammatory drugs like NSAIDs and steroids after an acute injury. In our above example, this is like hiring the construction crew and then giving them all large doses of Valium or other sedatives so they do slow and sloppy work (or keeping them readily supplied with endless 6 packs of beer all day). On the other end of that spectrum is prolotherapy, or injections to stimulate inflammation. In the right tissues like ligaments and tendons, this works well, as you can slightly re-injure the area to give the patient another bite of the healing apple.

Before we get to the ugly (chronic inflammation), let’s talk about the bad-abnormal healing. Probably the best example of abnormal healing is the replacement of normal healthy tissue with scar tissue. A model for this is the type of abnormal healing is knee cartilage surgery. In a micro fracture surgery there is cartilage healing via scar tissue (fibro-cartilage). Why does this happen? There are two big reasons. The first is that inflammation isn’t controlled and the second is that there aren’t enough stem cells. Take micro fracture for example, the surgeon pokes holes in the bone to help a cartilage “pot hole” heal over. The goal is to get bone marrow stem cells to leak through the holes and create cartilage. The problem is that the severe damage caused by the bone holes sets off a huge inflammatory fire. Speaking with the research scientists who have performed second look arthroscopies on animal models of micro fracture, I’ll never forget their comments about what the joint looked like one month after the surgery-“It looks like a bomb went off in there…” In our construction crew analogy, it’s like you bought all of the workers amphetamines-they now work hard and 22 hours a day, but their work is really sloppy and disorganized. This is like the fibro cartilage in micro fracture surgery-which is the wrong type of collagen for cartilage and not organized. What happens to the amphetamine driven construction site when you add more supervisors (stem cells) after micro fracture? You get better construction (cartilage). This has been shown in horses undergoing micro fracture-adding stem cells to the area produces better cartilage. In addition, other studies have shown that down regulating inflammation after it’s stimulated produces better repair. This is why we’re so concerned about bloody PRP injections, as they, like micro fracture, produce a huge inflammatory stimulus. This also why the Regenexx-SCP procedure doesn’t have these red blood cells and why our -SD and -C stem cell procedures have post injections designed to modulate inflammation.

So how about the ugly-chronic inflammation? There isn’t likely a bigger silent killer in our midst and also one that wrecks more havoc on the musculoskeletal system. However, this is very different than good or bad healing inflammation, so how can we reconcile the good, the bad, and the ugly. In chronic inflammation, there is a low level of activity that continues and isn’t functioning to finish any repair job. Picture our construction workers out there in 110 degree heat working 24 hours a day, 7 days a week for many years. While they are only told to work at a very slow pace, how long would it take before they just collapse? In chronic inflammation, many of the same signaling chemicals that are supposed to whip cells into a repair mode continue at very low levels and over time begin to damage and exhaust good cells. How does someone get this type of dysfunctional inflammation? Extra weight, low activity levels, a bad diet, and a drop in hormone levels as we age can all contribute to these low level of damaging chronic inflammation. In addition, getting dealt a bad genetic deck also makes things worse. This is the kind of inflammation that also damages your stem cells.

How do you know if you have this type of chronic inflammation? While there are a few blood tests, there may an easier marker. If you’re overweight, inactive, middle aged or older with high blood pressure and someone has placed you on cholesterol drugs or told you that you need them, it’s fairly likely that you have some or a lot of this going on. How you can you control it? A complete lifestyle overhaul for starters. Loosing weight, upping you exercise game substantially (i.e. way beyond taking walks around the block or three 30 minute gym machine workouts), and perhaps considering an age management program would be good places to start. Also take a look at our 10 Ten List for ways to help your stem cells as this has other things you can do, many of which are focused in this direction.

The upshot?  Understanding inflammation is important and you now know that there are three kinds of inflammation-one good, one bad, and one ugly. You want to promote the good, avoid the bad, and get yourself out of the midst of the ugly!

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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