Opinion: Patient reported motivations for seeking stem cell therapy and considerations for counseling

Stem cell therapies occupy a unique place in the American public’s consciousness which has led to excessive enthusiasm over their potential to cure orthopedic conditions. Much has been written about direct-to-consumer marketing of cell therapies for a myriad of medical conditions. Far less has been studied on the attitudes that drive many patients to seek stem cell and orthobiologic therapies for musculoskeletal conditions. Previously published research on patient motivations for seeking stem cell therapy to treat orthopedic maladies such as osteoarthritis and chronic tendinopathies has shown that some patients were motivated by factors not supported by current medical evidence. These differing responses strongly suggest the need for patient-centered counseling to address misinformation about stem cell therapies for musculoskeletal conditions and increase health literacy about outcomes of orthobiologics.


Introduction
Orthobiologics are substances obtained from the body used to reduce pain and aid in the repair of musculoskeletal conditions 1 . Their use, which has matured in the last 2 decades but still needs of more robust scientific evidence, has been conflated with stem cell therapy in the minds of both the public and some practitioners. The reason for the association is perhaps due to misleading claims by some providers offering direct-to-consumer regenerative and stem cell interventions and building on the public awareness and hype surrounding stem cells. Orthopedics and sports medicine patients account for over 68% of such clinics' clients [2][3][4][5] . Many orthopedic and sports medicine professional societies have published statements advocating for the responsible use of autologous cell-based interventions [6][7][8][9] . Previous studies have described direct-to-consumer marketing landscape of regenerative interventions that has focused on the allure of stem cells and misinformation in advertisements. Many such advertisements include pseudoscience and tokens of legitimacy which attempt to co-opt the scientific literature with false claims of efficacy [10][11][12][13][14][15] . As a result, patients are likely to have unreasonable expectations about the safety and potential efficacy of more common treatments or better established orthobiologics. Additionally, little is known about patient motivations for seeking stem cell and regenerative interventions or their sources of information.

Reasons why patients seek stem cell treatments and their information sources
As part of our routine practice in counseling patients about orthobiologic treatment options, we asked three questions through a standardized intake form: (1) Why are you interested in stem cell treatment for your condition?
(2) How did you find out about stem cell treatment for your condition? (3) Have you previously contacted a stem cell clinic? The responses to these questions were independently evaluated by two providers with experience counseling patients about orthobiologic therapies including platelet rich plasma and autologous minimally manipulated cell therapies from bone marrow or fat 16 .
We found that the most common reason why patients reported being interested in stem cell treatment for their condition was the desire to avoid or delay joint replacement or tendon repair. This was closely followed by motivations for treating or alleviating pain. Interestingly, many patients reported stem cells as being better than surgery or standard of care which has not been medically proven. Finally, some patients' reported their reason for seeking such therapies because stem cells can regenerate tissue or restore function, which has also not been validated for most orthopedic conditions 16 .
Our research has found most patients completed online research to learn about stem cell treatment for their condition and while we did not ask patients to specify which online resources, trusted online resources are most likely difficult for patients to discern. Many others were recommended such treatment from a friend or family member, or in some instances a healthcare provider. Other traditional and online media sources including social media, television, print advertisements and stem cell seminars were also reported sources of health information among those that patients evaluated. Finally, 40% of patients had prior contact with a stem cell clinic before reaching out to our consultation service.
Results from our studies surrounding patient attitudes for seeking stem cell and regenerative therapies for orthobiologics, and other studies outlining misinformation in direct-to-consumer advertising of stem cell therapy for musculoskeletal conditions 14 , strongly suggests the need for patient counseling and educational resources.

Discussion and Future Directions
Efforts to understand patients' knowledge and motivations when considering both orthobiologic and stem cell treatment are essential if clinical providers intend to adequately counsel patients regarding all treatment options and obtain informed consent if an orthobiologic is a reasonable treatment option for patients seeking novel biologic therapies. We learned that while many patients were motivated by a desire to manage symptoms of pain or restore physical function, others described motivations that are inconsistent with the current medical evidence.
We acknowledge that despite incomplete evidence in support of biologic therapies, patients remain interested in stem cell treatments for their orthopedic conditions and thus there is a dire need for ensuring appropriate counseling and communication with patients, and the need for validated resources to provide patients evidence-based information. To better provide patients with accurate information, we launched a regenerative medicine consult service and have engaged with thousands of patients seeking regenerative care. While orthopedists are trusted experts in musculoskeletal care, subspecialty experience in stem cell science or regenerative therapies varies among providers, creating the need to ensure standardization of how we communicate about such novel treatments and the provision of trusted sources of information for this emerging field.
Counseling practices should convey the circumstances for when a specific stem cell or orthobiologic therapy is appropriate and outline the skills for clinicians to debias patients against misinformation and stem cell hype while providing support and offering additional evidencebased resources that have been vetted by experts. Said resources should also be made available to patients online and in print as informational materials when possible 17 . Understanding patient motivations for such therapies remains an important first step to outlining the nature and pervasiveness of misinformation prior to developing best counseling practices and evidence-based patient educational resources. As growing evidence for orthobiologics is mounted, there is a need to best inform both providers and patients about orthobiologic and cellular therapies, effectively separating fact from fiction. This will enhance patient-clinician communication and shared decision-making that will best serve the clinical needs of patients.