The Napa Medical Research Foundation (NMRF), an independent 501(c)(3) non-profit foundation, funds a number of research projects for the Bodor Clinic. The goal of the NMRF is to conduct clinical and basic science research on the prevention, diagnosis, treatment and cure of conditions affecting nerves, muscles, bones and joints in adults and children and to disseminate its findings within the medical profession and target populations to benefit the public good and humanity as a whole. For more information about the NMRF, visit www.napamedicalresearch.org.
Diagnosis of Neuropathies
One of our basic science research projects aims to determine whether nerves, like skin, muscles and bones, adapt to mechanical loading by enlarging. Currently when nerve enlargement is seen on ultrasound it is considered abnormal and may result in medical or surgical treatment. However, if nerve enlargement is sometimes normal, then this needs to be known or else patients might get the wrong diagnosis and unnecessary treatments which could be harmful. A related project is whether and to which degree nerve cross-sectional area is related to height. The ultimate goal of this project is to improve our accuracy in using ultrasound to determine the presence of neuropathies and develop new treatments.
Mathematical Modelling of Childhood Diseases
We have used mathematical modelling to answer some unknown questions relating to the most common lethal genetic disease of children, Duchenne Muscular Dystrophy (DMD), foremost of which is why is it that children born with an unchanging genetic defect and the missing protein dystrophin are able to walk around the age of 4 but then lose this ability over time, ending up in a wheelchair by the age of 12 and dying before the age of 30? The cause for this has been attributed to increasing muscle inflammation. Our model consistently predicted that the progressive decline is not primarily attributable to inflammation but to exponentially increasing load on muscle fibers related to increasing height and loss of muscle fibers. Our model explains how glucocorticoids, the only drugs proven to retard the progression of disease, work by stunting growth and limiting the enlargement of muscle fibers. Our model predicts that drugs being currently developed to control the inflammation will fail while those addressing the missing dystrophin are more likely to succeed. Furthermore, our model predicts that a novel drug promoting muscle growth by adding more fibers (hyperplasia) as opposed to increasing their size (hypertrophy) would be successful at preserving function and prolonging life.
A translation of our research on DMD relates to the development of a new theory on the etiology and treatment of Sever’s Disease (SD), funded by the NMRF, an extremely common and bothersome childhood disease which for over 100 years has been attributed to inflammation of the growth plate. Using a similar mathematical model as with DMD, we calculated that there would be progressively increasing load collagen in tendons and fascia in kids with SD. Using MRI and ultrasound imaging, we have not found evidence for a disorder of the growth plate, and by treating the problem opposite to how it has been treated for the last 100 years, have been successful in curing 95% of children who have had symptoms ranging from 3 months to 3 years in approximately 2 weeks.
Prevention of Sports Injuries
Another area of mathematical modeling relates to anterior cruciate ligament (ACL) injuries, particularly in females. ACL injuries are debilitating and even with the best ligament repair techniques predispose to the development of chronic knee pain over time. Knowing what muscular and mechanical factors might predispose to these injuries is likely to be successful in preventing them and leading to better treatments. The primary muscular restraint to ACL injury has been considered the hamstrings and more recently, the gluteus medius muscle has gotten attention as an important stabilizer of the hip, knee and pelvis. The quadriceps, the primary stabilizer of the knee, has been relatively ignored because when the quadriceps is activated it tenses the ACL. However, what current models have ignored is that tension on the ACL, if unaccompanied by twisting of the knee, has not been show to injure the ACL. No cases have been reported in which a healthy normal individual performing knee extension exercises with weights tore their ACL. We believe that the quadriceps is the primary stabilizer of the knee and one of the primary reasons why females develop ACL injuries at a higher rate is because of the change in angle of the quadriceps vector that occurs at the time of puberty.
The intervertebral disc is the primary cause if not the contributing factor to most chronic back pain. When improvement of sleep, exercise, and elimination of contributing factors and the passage of time does not help, biological treatments, consisting of platelet rich plasma or stem cells, can be done for the discs with the goal of healing tears within the annulus fibrosus. We use platelets, functioning specifically as active “nanorobots” as opposed to sources of growth factors, towards this goal, and are researching which type of patients benefit most and how the technique can be improved further.
We developed a technique and have had preliminary excellent results injecting platelets or mesenchymal stem cells into the cervical facet joints, for patients who sustained whiplash injuries. The ultrasound-guided technique is done with the smallest possible needle and without use of radiation or contrast dye. We have completed a study showing 97% accuracy for intra-articular injections as confirmed via fluoroscopy and are preparing our results for publication.
We have had over a 90% success rate using platelets for patients with greater trochanteric pain syndrome and tears of the gluteus tendons and plan to recruit patients for a double-blind randomized controlled study. Along with colleagues at Stanford, we have an ongoing study and have submitted a paper for publication on optimal protocols using platelet rich plasma for high hamstring tendon tears/tendinosis in elite and recreational athletes.
Ultrasound Guided Surgery
Arthroscopic surgery was a major advancement over open surgery, allowing smaller incisions and a faster recovery for many orthopedic applications. Nevertheless, arthroscopic surgery depends on the insertion of cameras and the creation of a working space inside the body to optimize visualization and provide space for instruments. Ultrasound uses sound waves instead of light and does not require that a camera be inserted inside the body. With ultrasound it is possible to visualize structures such as the ulnar artery and nerve in the case of carpal tunnel surgery for example, which are “behind walls” and would not be seen using light. We have partnered with companies producing ultra-minimally invasive instruments to develop ultrasound-guided techniques for carpal tunnel release, exertional compartment syndrome fasciotomy, ulnar nerve decompression, trigger finger, plantar fascia release, radiofrequency medial branch neurotomy and hopefully soon single-bundle rotator cuff repair. The advantage over arthroscopic surgery is a smaller incision, local anesthesia, no sutures, less post-operative pain and a faster return to activities of daily living and sport.