Thursday, December 11, 2008
We are pleased to announce that our new web site has launched! Checkout www.orthohealing.com to read more about our practice. We want this website to be a resource for you, so please feel free to drop us an e-mail and let us know what you would like to read about!
This site replaces the former www.prpinjection.com
Sunday, November 9, 2008
With the election of a new president, there will certainly be change. Recently in the Washington Post & CBS news, it was reported that Barack Obama intends to reverse the Bush policy on stem cell research. It is believed amongst the scientific community that stem cells offer abundant potential for challenging conditions including parkinson's disease and osteoarthritis among others. However, adult rather than embryonic stem cells are available with current technology and have little controversy associated with their use. The only problem is that harvesting them requires inserting a metal rod into the bone marrow to extract it. Hopefully, soon we will be able to draw adult stem cells from peripheral blood (drawing blood from the arm & processing stem cells). Clearly the orthobiologic field is growing, and we will learn more about the promise of stem cells in the near future whether adult or embryonic cells are utilized.
Sunday, October 5, 2008
PRP or Platelet Rich Plasma has seen increased use in professional athletes. Recently, Takashi Saito, a star pitcher for the LA dodgers suffered a tear of his ulnar collateral ligament. In efforts to accelerate healing and to avoid a Tommy John surgery, Saito elected to receive the prp injection graft. As a result, He was able to pitch in the playoffs without limitations.
We have treated other professional athletes with similar results. PRP can be thought of in both high level athletes to accelerate recovery or in chronic non-healing injuries that have persisted despite conservative treatment or even surgery.
Hopefully as more high level athletes receive this treatment, it will increase awareness about this procedure that has very little downside and tremendous potential.
Also, Stanford University Football players have been receiving platelet Rich Plasma injection grafts with success.
There is currently a multi-center FDA study on tennis elbow that will be enrolling more patients soon.
Also we are working on another PRP knee arthritis study based on the previously successful pilot study.
As testament to the growth in the biologic sector, numerous orthobiologic companies worldwide are funding research & are obtaining grants with PRP use.
Applications of study include plantar fasciitis, achilles tendinosis, congestive heart failure, peripheral vascular disease, systemic sclerosis (scleroderma), knee MCL tears, perodontal tissue, aortic aneurysms, coronary artery bypass, tennis elbow, and rotator cuff tears among others. I am currently conducting research specifically on knee arthritis.
Following the well publicized NEJM article suggesting the ineffective role of arthroscoopy in arthritis, many are looking for alternative treatments that are cost effective with little risk. This article from the LA Times highlights some options including an exercise program, physical therapy modalities, and weight loss. While I agree that physical therapy is beneficial, as is maintaining an active lifestyle; often we need to address the internal biochemical environment of the joint. This may be achieved with Platelet Rich Plasma Therapy. Our knee arthritis clinical trials continue to show promising results in most cases. I have the 3 mo data in & I am collecting 6 mo data in a few weeks from now. These results will be published.
Sunday, September 14, 2008
Despite the predominance of knee arthritis in the US, there are few good options for patients hoping to relieve pain & improve function. Physical therapy can help to increase muscle tone to the quadriceps muscles to reduce excessive workload on the joint. Also inflexible muscles can be stretched to restore the normal kinetic chain to reduce pain & prevent further aggravation of symptoms. Orthotics & braces may decrease the mechanical forces that are adding stress on the joint. However these treatments will not influence the underlying inner cartilage defects and biochemical environment.
Knee arthroscopies are quite popular and certainly have a role in particular cases including severe meniscus and ACL tears. However in a recent study in the New England Journal of Medicine, there was no demonstrable benefit of knee arthroscopies for moderate to severe knee arthritis compared to physcial therapy and medications. 92 surgical patients and 86 controls (Physical therapy & medications) were compared over 2 years.
The article was reviewed recently in the LA Times.
This article should raise awareness that we need to develop innovative approaches to maximize healing in an increasingly active population. Over 27 million Americans have osteoarthritis.
We are performing Platelet Rich Plasma Injection Grafts in hip and knee arthritis with encouraging results. The field of orthobiologics is rapidly growing and promises to deliver new approaches to treating tendon and cartilage disorders. In my practice we are treating meniscal tears immediately to accelerate healing. Many patients do not need an arthrocsopy after 2 months of the PRP graft and physical therapy. By potentially avoiding surgical meniscal repairs, we hope to reduce the incidence of subsequent arthritis. We are conducting studies to further refine the treatment to achieve a maximal result.
Wednesday, August 13, 2008
My PRP review article is now published in the Current Reviews in Musculoskeletal Medicine. http://www.springerlink.com/content/5708408818n30275/ The online version is available, and the printed version is coming soon. The article includes nearly 50 literature sources and provides a comprehensive overview regarding platelet rich plasma usage in orthopaedics and sports medicine. Also, the review discusses the promising realm of orthobiologics and describes experiences with using platelet rich plasma for cartilage disorders and osteoarthritis.
I have been conducting research on arthritis with encouraging results so far. I am planning on collaborating with other leading physicians and publishing many more articles to advance the field of orthobiologics.
Thursday, July 17, 2008
Gosens & Sluimer from the Netherlands, just reported on a prospective, double blinded, randomized study comparing PRP to cortisone injections in the treatment of 100 patients with tennis elbow. They used a visual analog pain score (1-10) & a DASH score to measure treatment response by 24 weeks. Both groups demonstrated initial improvement. However, by 24 weeks the cortisone group had a recurrence of pain whereas the PRP group continued to have improved pain scores. 1 and 2 year follow up results will be reported in the future.
This article originated from St. Elisabeth Hospital, Tilburg, the Netherlands.
Prior research has showed that after 4-6weeks tendons are no longer inflammed, but rather become thickened, scarred, & fibrotic with poor blood supply. Therefore at this point the proper nomenclature is "tendinosis" not tendinitis. With this understanding we try to facilitate healing by increasing blood flow and breaking up scar tissue.
Wednesday, June 18, 2008
Using One's own adult stem cells taken from bone marrow, researchers are studying the effects of potentially preventing amputation in ischemic (poor blood supply)limbs. Doctors do a minimally invasive procedure obtaining stem cells, then much like PRP or platelet rich plasma they increase the concentration and then inject it. Doctors are injecting multiple sights just beneath the tissue in the blood flow deprived extremity. We look forward to following this study & the results that follow.
Perhaps the next frontier beyond PRP is Stem Cells. While the topic is the subject of much controversy politically, technology now allows us to utilize adult stem cells opposed to embryonic cells to treat disease.
Stem Cells are the birthplace of platelets rich in healing properties, which can potentially program cells to regenerate tissue & cartilage. Currently stem cells can be retrieved via embryo (controversial in US), umbilical cord, bone marrow, peripheral blood, & in the near future adipose (fat) cells via liposuction.
Peripheral blood, or simply drawing blood from a patient's arm is the least invasive & most promising method. Patients require a shot or medication to release stem cells from the marrow to the blood stream. It can then be processed & used for injection. In the future patients may have the option to store unused stem cells for future use as well.
Stem cells are being used in the US mostly for cancer patients to assist in recovery from the ill effects of chemotherapy. A few practitioners are using them orthopaedically with reportedly good results in arthritis. Internationally there are centers where patients seek alternative treatment to serious diseases like spinal cord injury, multiple sclerosis, and ALS.
There is an adult stem cell organization which lists numerous articles & personal stories.
A new textbook was released by Jennifer E. Woodell-May and William S. Pietrzak which includes a chapter reviewing PRP. The chapter includes a literature review including case reports that suggest the multitude of potential applications.
One of the chapter's authors, Jennifer Woodell-May has produced insightful research regarding the role of growth factors & their concentrations.
Sunday, May 4, 2008
We are beginning clinical trials of Platelet Rich Plasma (PRP) injections in patients suffering with knee arthritis. There is an increasing "boomer" population with earlier knee arthritis as a result from prior trauma including meniscal tears & arthroscopies with scarring and cartilage loss etc. This phenomenon is termed "chondropenia." We are searching for non-invasive alternatives to knee replacements in these active individuals.
Patients will receive a series of injections under ultrasound guidance to insure proper placement. X-rays and MRI's, are taken into account & cartilage growth will be measured on serial ultrasound evaluations. Multiple pain score measures will be recorded as well. We plan on publishing this data so that the medical community can learn more about the promising role of PRP injections in cartilage disorders.
Wednesday, March 19, 2008
After initially successfully injecting many patients with tendon & ligament problems, we have been expanding use of PRP to numerous regions including greater trochanteric hip bursitis among others.
A "bursa" is a small fluid filled sac that can be found in many areas that reduces friction of gliding tissues. This bursa fills with synovial fluid as a result of mechanical trauma/irritation & causes considerable pain. Specifically there is a bursa that lies on top of the greater trochanter (femur/hip bone). This pain can be debilitating. Often cortisone injections can be successful & provide temporary relief. However overuse of cortisone can cause adverse effects & should be avoided. Therefore PRP (Platelet Rich Plasma) injections under ultrasound guidance offer an appealing & safe alternative.
Below are case reports from a group in Texas that successfully injected PRP for hip bursitis.
Tuesday, February 26, 2008
In a Jan/Feb 08 issue of Practical Pain Management, the authors describe PRP use in tendon injuries, spine conditions, as well as hip & knee arthritis. The article emphasizes a need for agreed upon nomenclature.
An interesting concept addressed is whether a gel matrix is needed for the platelets to adhere to the target site. Because of their structure tendons & ligaments may not require the gel, however it is not known if adding calcium chloride with thrombin to the PRP is needed in joint spaces like knee & hip arthritis. Further data needs to compare the usage with gel versus without.
The article showed x-rays post prp injection with subtle smoothing of a previously arthritic femoral head (hip bone). It is not clearly known how PRP acts on arthritis, however a particular growth factor found in PRP, TGF-B has been linked to cartilage growth (chondrogenesis). Furthermore, another study showed that PRP influences hyauloronic acid production which balances cell proliferation (angiogenesis). Also, the authors suggested a possible role in serotonin decreasing pain. Lastly, utilizing "stem cells" (the birth place of platelets and their precursors)may offer the most ultimate potential.
Sunday, January 27, 2008
An article from Jan 08'in the JBJS (Journal of Bone & Joint Surgery), that documented low energy shockwave therapy was effective in treatment of non-healing achilles tendinosis. The randomized controlled trial showed that 64% of patients receiving shock wave(group I) were completely recovered or much improved, versus 28% of those who received an eccentric loading exercise program (group II).
The study looked at 50 patients who have had pain for > 6months & failed conservative treatments.
I have been treating many patients lately (more than 50, with various injuries including achilles tendinosis, plantar fasciitis, tennis elbow, & bicep tendonosis with favorable results. I have all patients complete questionnaires 6 weeks after their initial treatment to determine a useful role for shockwave in my practice.
Ultimately I invision a protocol implementing various modalities to maximize the body's innate ability to heal itself. Furthermore, I am exploring the potential role of hyperbaric oxygen therapy.
I will soon post results from the 150 or so shock wave treatments I have done. However, larger studies requiring double blinded methods are required so that we can learn more about shockwave therapy.
Thursday, January 17, 2008
Many trials are in the pipeline in efforts of obtaining FDA approval for PRP injections. There is a multi-center placebo controlled double blinded study underway looking at plantar fasciitis(heel pain) & lateral epicondylitis (tennis elbow).
Also, Thanks to the many patients inquiring about info on docs around the country performing PRP procedures. Feel free to contact any of those listed in the link performing this particular study. At some point I may have a list of various PRP docs out there to help patients out. Please Continue to send requests.
On another note, we are currently examining the efficacy of Platelet Rich Plasma with osteoarthritis. We are collecting objective data on all patients injected.
Monday, January 14, 2008
A new article from the Journal of Cellular Physiology presented some new insights into the role of PRP in tendon healing. After injecting PRP into mice patellar tendons, accelerated healing was demonstrated. The PRP had an 8.8 times platelet concentration above baseline versus whole blood.
Circulation derived cells play a key role in tendon healing. Blood flow is very important in connective tissue regeneration. Tendons typically have a poor blood supply (only 1/3 of the amount found in muscles). This study showed increased quantity of these healing cells in the early phase of tendon repair. Unfortunately, these helpful cells normally disappear with time. Therefore prolonging their presence is advantageous. Also increased type I & III collagen and macrophages were increased; supporting that PRP promotes tendon healing
Sunday, January 13, 2008
A new article from the British Journal of Sports Medicine Nov 07, reviews PRP (Platelet rich Plasma) use in sports medicine. After a good thorough review, they point out that using growth factors is considered a doping violation by the WADA (World Anti-Doping agency). THE WADA created in 1999 to promote, coordinate, and monitor the fight against doping in sports. The WADA prohibits use of a particular growth factor, Insulin like growth factor (IGF-I). However scientific literature has shown that IGF-I is not increased in PRP. This misunderstanding of PRP may create an ironic situation where this cutting edge technology may be available to the weekend warrior, but not the Olympian. Keep in mind that "growth factors" are different from "growth hormones."
As PRP use increases so does the need for the scientific community to comprehend it's applications & mechanism of action. Hopefully the application of PRP will be recognized as a natural and safe alternative to promote healing in high level athletes and the weekend warrior alike.
Growth Factor Delivery Methods in the Management of Sports Injuries:The State of Play http://bjsm.bmj.com/cgi/content/abstract/bjsm.2007.040071v1
Thursday, January 3, 2008
A growing number of physicians are using musculoskeletal ultrasound to guide various injections. As a leading imaging technique in Europe, ultrasound is safe, economic, convenient, & effective in diagnosing many injuries. The technology has dramatically improved and allows us to visualize nerve & tendon fibers. While the quality is not quite MRI caliber, ultrasound allows for dynamic (motion studies). In other words, ultrasound allows functional evaluation of an injury with movement, whereas MRI takes a still image. Also, ultrasound has color doppler that shows areas of blood flow changes (called neo vascularization). This allows us to deliver the PRP within a millimeter of the target site, or even discover other regions that are affected.
Ultrasound technology continues to grow. I just upgraded to this Sonosite portable machine with color doppler.