New Platelet Rich Plasma (PRP) review article for tendon injuries and arthritis

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.

http://www.ppmjournal.com/abstract.asp?articleid=P0801F01

http://prpinjection.blogspot.com/2007/11/new-article-on-osteoarthritis-and.html

Treatment of Achilles Tendinosis with Shock Wave Therapy

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.

http://www.ejbjs.org/cgi/content/abstract/90/1/52

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.

Multi Center Clinical trials of Platelet Rich Plasma Underway

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).

http://www.biomet.com/patients/clinical_recruitment_recover.cfm

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.

January 08' Platelet Rich Plasma Enhances Tendon Healing

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

http://www3.interscience.wiley.com/cgi-bin/abstract/117880365/ABSTRACT?CRETRY=1&SRETRY=0

A need to Clarify Platelet Rich Plasma use in International athletes

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

Ultrasound Guided Platelet Rich Plasma Injections

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.

New Platelet Rich Plasma Web Site

I recently launched a web site on PRP. It is another resource for health professionals & patients to learn more about this emerging therapy. Additionally, I will be hosting a conference in early May 2008, in Los Angeles to train other physicians on the use of PRP along with musculoskeletal ultrasound guidance.

www.PRPinjection.com

The site will include testimonials as well as promote further communication amongst patients.

Platelet Rich Plasma Cartilage/Arthritis Study in Rabbits

In a recent study from October 2007, a group from China was the first to document platelet rich plasma's ability to support chondrogenesis (cartilage cell growth). They took cartilage from the rabbit's ear, & mixed it with PRP and calcium chloride & thrombin (to form a matrix). Two months later, hard knobbles were found and seen on MRI, as well as histological analysis (cellular) and staining confirmed cartilage growth. Interestingly, there was no cartilage growth with the control group that received PRP alone. This study demonstrated successful formation of new cartilage with an injectable graft using PRP and cultured chondrocytes.

http://www.joms.org/article/PIIS0278239106021070/abstract

Santa Monica Orthopaedic Group Awarded FIFA Center of Excellence

Our practice was awarded the title of a FIFA Medical Center of Excellence. The Fédération Internationale de Football Association (FIFA) is an association governed by Swiss law founded in 1904 and based in Zurich. They oversee one of the world's largest international sporting events, The World Cup. FIFA hopes to reach out and touch the world, using football(soccer) as a symbol of hope and integration.

Our practice was selected after demonstration of clinical education, research, and injury prevention. Other centers chosen include St Marianna University School of Medicine in Kawasaki, Japan, The Adidas Sports Medicine Centre in Auckland, New Zealand, the Centre for Exercise Science and Sports Medicine at the University of Witwatersrand in Johannesburg, South Africa, and the Orthocentre of the Technical University, Munich.

There will be a ceremony at our facility Monday December 10th, 2007.
These designated centers are open to every soccer player looking for therapy or a second opinion on a specific injury.

http://www.fifa.com/aboutfifa/developing/releases/newsid=653724.html

My Colleagues, Bert Mandelbaum MD & Michael Gerhardt MD are team physicians for the US National Soccer team.

We have used platelet rich plasma on professional soccer athletes to accelerate recovery.

http://prpinjection.blogspot.com/2007/10/cbs-news-with-katie-kouric-prp-feature.html

Extracorporeal Shockwave Therapy to Encourage Natural Healing in Tendon Injuries?

After immersing myself in the study of Platelet Rich Plasma Therapy and the larger scope of "biologics," I have been drawn to the concept of maximizing the body's natural ability to heal itself. PRP does not create a new injury, to stimulate healing, but rather takes the body's normal reaction to an area & places it at the site of limited healing. After injection patients experience discomfort above baseline anywhere from 2-5 days. Clinical benefits are often not immediate, as the cellular changes take up to months. However, we have seen dramatic improvements in most cases.

Perhaps an earlier generation in the philosophy of promoting natural healing lies in shockwave therapy. Shockwaves are administered in an office setting for a series of 3treatments at one week intervals , lasting 3 minutes each. The concept is that by alternating positive & negative pressure, shockwaves induce microtrauma (minor injury) that sends a signal to the brain to stimulate healing to an area previously dormant & injured.

We know that after a few weeks, tendons are not inflammed, but rather form a scarred & thickened structure, with blood flow changes. This new understanding has flipped our approach to tendon injuries, now termed "tendonopathies." Treating a chronic tendon injury with cortisone or anti-anflammatory medications not only has adverse side effects, but doesn't make sense.

Shockwave therapy was initially developed to break up kidney stones. However, the Europeans have been using this treatment on tendon injuries for years. It is now FDA approved for use in the U.S.

I was given a free machine for a 6 wk trial. I treated 14 patients last Tuesday. Apparently, patients may experience an improvement following the second treatment. This modality is appealing, because it is less invasive than an injection, and results are more immediate (if they occur) than PRP.

Ultimately shockwave therapy may be uses along with PRP in a protocol to maximize therapy. My colleague, a podiatrist has seen terrific results in patients that have failed conservative treatments for heel pain(achilles tendonosis & plantar fasciitis). The procedure is generally well tolerated.

Attached is the web site to learn further. I will continue to post my experiences with this new treatment. There are only 60 machines in the U.S.


www.dolorclastmethod.com

Cigarette Smoking May Limit Platelet Activity in PRP

A study from Istanbul, Turkey looked at the effects of cigarette smoking on the viability of platelets. Platelets are very fragile and special care must be taken in preparing them for injection after increasing their concentration. However, research suggests that smokers may have increased free radicals that affect the oxidant/anti-oxidant balance, thus reducing platelet activity.