When Ira
Schneider’s right hip started to hurt, the Los Angeles-based chiropractor
wanted to avoid a repeat of the surgery he’d undergone on his left side, and
the months of painful recovery that followed.
Instead, he
turned to platelet-rich plasma therapy, better known as PRP, a treatment
gaining ground after headlines touting its use by elite athletes including
golfer Tiger Woods, tennis’s Rafael Nadal and basketball’s Kobe Bryant. Last week, Andrew Bynum, of the Philadelphia 76ers’ NBA team, said
he’ll travel to Germany next month for the procedure, in which a
concentrated dose of tissue-repairing platelets taken from the patient’s blood
is injected into an injury site.
Costs
running as high as $250 an injection that aren’t covered by insurance and
uncertain scientific evidence about the therapy haven’t stopped people from
peppering doctors with requests to try it. While probably hundreds of athletes
have undergone PRP since 2009, when Woods first used it for a painful knee, it
hasn’t been subject to large-scale testing in wide groups that include
less-athletically gifted people.
“Athletes
are always seeking an edge and, at an elite level, it makes sense for them to
look for any possible shortcut to healing,” said Dennis
Cardone, at New York
University’s Langone Center for Musculoskeletal Care in Manhattan. “But too often the newer procedures are done
in people who don’t need that physical edge, without good evidence they
actually work.”
Testing
Requirements
While drugs
generally undergo 10 or more years of regulated clinical trials before being
sold, treatments such as PRP don’t face the same requirements. The Food and Drug Administration doesn’t overview therapeutic
procedures, as long as the blood product isn’t shipped across state lines, is
for individual use only and no claims are made that it will correct a specific
medical problem, Heidi Rebello, an FDA spokeswoman, wrote in an e-mailed
response to questions.
As a
result, most people learn of treatments such as PRP through the Internet,
word-of-mouth or news reports after they’re used by celebrities seeking quick
results.
In PRP’s
case, the use of the therapy by Pittsburgh Steeler professional football player
Hines Ward, just prior to his winning Super Bowl
appearance, Alex Rodriguez of the New York Yankees, and Bryant, of the National Basketball Association’s Los Angeles Lakers, created a drumbeat of headlines about the
procedure, following Woods’s announcement he had used it.
PRP is one
of a wide range of new treatments, including whole-body vibration and
hyperbaric therapy, being used by elite athletes to recover from career-slowing
injuries. Whether shot- gunning platelets using PRP helps in all cases remains
an open question, researchers have found.
Growth
Factors
The therapy
can take from about 20 minutes to two hours, starting when a doctor draws a
small amount of blood from a patient. The blood is placed in a centrifuge to
separate out platelets that carry so-called growth factors, which are thought
to help naturally in healing. The platelets are then re-injected into the
patient at the point of injury, the idea being that the regenerative properties
of the growth factors will work even more efficiently at a higher
concentration.
Because the
plasma is an extract of the patient’s own blood, there’s little danger of an
adverse reaction or disease, and it can be given multiple times, said Allan Mishra, a physician at Stanford University Medical
Center’s clinic in Menlo Park, who offers the procedure in his
practice.
Schneider,
56, said he learned about PRP while working in his job as a chiropractor with
athletes at California State University, Northridge. While he said he isn’t
the type to jump on the latest hot therapy, he was desperate to avoid another
hip surgery.
Pain
Free
The result
for him “has been pretty much amazing,” he said in a telephone interview. “It’s
been six or seven months since my last injection, and I’m still 75 percent pain
free. It’s a wonderful alternative to having a replacement done.”
Since Woods
first said he had used the therapy in 2009, though, scientists have reported
mixed results in limited trials done with relatively few participants.
In January
2010, for instance, a report published in the Journal of the American Medical Association, or JAMA, found PRP to be no more
effective than salt water at inducing healing in 54 patients with injured
Achilles’ tendons. In separate trials done last year, PRP lowered blood loss in
81 patients with knee replacements, and lessened pain for 21 with tennis elbow.
Those
trials, though, didn’t directly measure whether the therapy increased the speed
of the healing process. Other studies are in progress in ankle sprains,
cartilage degeneration, muscle injuries, rotator cuff injuries and more,
according to the U.S. website ClinicalTrials.gov.
Little
Known
Leon
Creaney, a London-based physician, wrote in a commentary last year in the British Journal of Sports Medicine, that too little is known to offer
use of PRP to patients, except on an experimental basis. The lack of a standard
procedure in administering the therapy may send “a completely confusing
message” to cells that affect healing, he wrote.
The
anecdotal result reported by athletes could be nothing more than a placebo
effect, in which a patient’s condition will sometimes improve simply because
the person has the expectation it will be helpful, Creaney wrote. The only way
to know for sure is to test large numbers of people in a blinded trial.
“It would
seem hopelessly optimistic and naive to presume that we are accurately
reproducing biological complexity” that occurs naturally within the healing
process, Creaney concluded in the article.
Despite
this, the therapy is entering the mainstream as a less-painful and
time-consuming alternative to surgery, according to Mishra, the Menlo Park
clinician.
Thousands
Done
While
there’s no way to determine how many PRP procedures have been done in the U.S,
Mishra said the number may be in the thousands.
“We’re not
quite the blind caveman feeling around in the dark on this,” said Mishra, who
has been credited with creating the PRP system in the U.S. “There are a few
cracks of light. It’s just going to take some time to understand it. You can’t
do randomized control trials on NBA players.”
Mishra
offers the therapy in his practice and is studying its usefulness for a variety
of ailments, including tennis elbow, which he says is currently the
best-supported use for the therapy.
Whether
unproven therapies should be undertaken for patients that request them is a
“complex” issue, Mishra said. “It’s messy, and it’s fascinating. The enthusiasm
for the therapy is partly driven by the patients themselves in this case, and
we should embrace that.”
Two New
York physicians who are top specialists in caring for the body’s complex system
of joints show the range of opinions on the questions.
No
Confidence
Giles
Scuderi, a surgeon
who specializes in knees at Insall Scott Kelly Institutes for Orthopaedics and
Sports Medicine in New York, says studies done on PRP haven’t given him enough
confidence in the therapy to offer it.
NYU’s
Cardone said that while he doesn’t push PRP he will perform the procedure for
patients who ask for it. First, though, he said he makes a special effort to
ensure they understand that the therapy, while safe, hasn’t been proven to work
during wide testing in multiple groups of people.
The
Internet traffic and news reports put doctors in a bind, Cardone said,
balancing their wish to work with their patients on new treatments with
concerns about using a procedure that hasn’t been proven.
While his
patients increasingly ask for PRP, Scuderi said he refuses to do the procedure.
‘Questionable’
Science
“The
science is still questionable” Scuderi said, and the injections aren’t covered
by insurance.
Recreational
athletes “don’t realize that the elite athlete, because it’s their livelihood,
can get rehab every day,” Scuderi said in a telephone interview. They have
resources “not available to the amateur, and a greater time commitment because
it’s financial for them.”
Schneider,
the Los Angeles chiropractor who had the therapy in his hip, said he was about
a month away from having surgery again when he decided to try PRP.
In 1980,
Schneider was a good enough athlete to try out for the U.S. Olympic team in
volleyball. Because it was a boycott year, he went instead to Europe and
played there professionally, he said. Soon after that, he had his first
hip operation.
“I
recovered from the surgery,” he said. “But that was the end of volleyball.”
Now he’s
glad he found PRP as a way to avoid a third operation and has returned to
cycling, he said.
Quick
Recovery
For others
using PRP, the advantage is less about the pain of an operation and more about
getting back to their sport more quickly.
That was
the case for Mark
Fretta, 35, once
the world’s top-rated triathlete, who said he used the experimental procedure
before competing in the U.S. Olympic trials in May.
Fretta said
had suffered a hamstring tear prior to the trials and, figuring it may be his
last chance to compete in an Olympics. He was devastated, he recalled.
Undergoing PRP seemed a reasonable bet to make, he said, since getting back to
training even a day earlier would help him better prepare.
After the
injection, Fretta -- who was ranked No 1 in the world in his sport in 2006 --
competed pain-free in the trials after just under four weeks of recovery time,
compared with the 6 to 8 weeks normal for the injury.
Though he
didn’t qualify, he says he was happy he got the chance to try.
“I think
the PRP injection I received was a huge accelerant in my healing process,” he
said. And although he was advised before using it that the scientific verdict was
still out, “I’d recommend it to my friends.”
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