Platelet Rich Plasma (PRP) is the new buzz word in the sport science and medicine community, or so says the current media. The move towards regenerative medicine technologies in injured sports people is understandable, although worrying, as athletes strive to come back sooner from injury. Mixed Martial Arts is no exception with two high profile examples of athletes in this year alone. Demetrious Johnson, current UFC flyweight champion, and Gray Maynard, former UFC Lightweight number 1 contender, both speak on the virtues of autologous blood product therapies.
In fact both athletes are proponents of platelet rich plasma therapy injections: Johnson, for his recent shoulder injury, and Maynard, for his knee. Both of which were alongside surgical, arthroscopic procedures.
However, as role models to their peers both current and future, does the positive press provided by these fighters, follow the current scientific evidence base. Or more simply- do they work?
Professor Nicola Maffulli of the Department of Musculoskeletal Disorders at the University of Salerno in Italy currently suggested in an editorial (May 2013) for the British Medical Journal that no they probably do not. She outlines that whilst these novel therapies are reported to accelerate recovery, and are heavily promoted to athletes, they are actually supported by poor evidence. She sites that the global market for PRP as £2.9m (or $4.5m), and that projections show an expected worth of $120m by 2016 (Global Data 2010). Perhaps more fashion over finance then? More trade than treatment at the base of this new trend.
PRP therapy
The process of PRP has two stages, which commonly (but do not have to) occur alongside surgical intervention. Firstly, blood is taken from the patient and combined with acid citrate dextrose solution to prevent it coagulating. The blood is then placed in a centrifuge, a piece of specialist machinery, which use the centrifugal force to separate different density constituents of the blood, by rapidly spinning the solution. This will remove the red blood cells and platelet poor plasma from the highly enriched “platelet rich plasma”. This new PRP solution will have 5 times the normal concentration of platelets per microliter (Marx 2004).
The process of PRP has two stages, which commonly (but do not have to) occur alongside surgical intervention. Firstly, blood is taken from the patient and combined with acid citrate dextrose solution to prevent it coagulating. The blood is then placed in a centrifuge, a piece of specialist machinery, which use the centrifugal force to separate different density constituents of the blood, by rapidly spinning the solution. This will remove the red blood cells and platelet poor plasma from the highly enriched “platelet rich plasma”. This new PRP solution will have 5 times the normal concentration of platelets per microliter (Marx 2004).
This significantly increased platelet concentration is then combined with thrombin (a coagulation factor protease) and calcium chloride (a salt), to stimulate certain small particles in the solution: alpha granules.
The activation of these particles causes a release of a vast number of cytokines and growth factors- which are capable of stimulating tissue growth- and as such, repair. This synthesis of new tissue and promotion of revascularisation, theoretically would then point to improved healing and acceleration of injury repair. No wonder then, in a sport where long delays between fights and the pressure of rapid return to the cage, could potentially mean an end to one’s career- it is no surprise that these athletes will jump on the PRP band wagon.
MMA vs PRP
Obviously in MMA, injuries are common. The strains of the multiple, long and arduous training camps each fighter goes through is likely to make its mark. The history of training in most athletes, starting at a young age with wrestling or Taekwondo or jiu jitsu for example, will also mean repetitive stresses throughout the body in different joints.
Obviously in MMA, injuries are common. The strains of the multiple, long and arduous training camps each fighter goes through is likely to make its mark. The history of training in most athletes, starting at a young age with wrestling or Taekwondo or jiu jitsu for example, will also mean repetitive stresses throughout the body in different joints.
In MMA all joints and muscle groups are placed under the hammer. Wrestler’s may have a slightly greater tendency to knee injury (due to time spent kneeling or performing takedowns) and Brazilian Jiu Jitsu practitioners may have a greater number of shoulder and elbow hyperextension strains- however in general terms, for the average MMA fighter, all areas are placed under stress.
Therefore, if I were to use an MRI scanner to investigate the natural anatomical state of 100 MMA athletes- a large percentage would have underlying tendon, cartilage or muscular problems. This is similar in most athletic populations. Kaplan et al. (2005) found the presence of asymptomatic, incidental articular cartilage lesions on 47.5% of his group of professional basketball players. Meniscal tears were presents in 20%.
Therefore, to start, just because an arthroscopy or scan says you have an injury, it does not necessarily mean this is the cause of your pain- or if it is- it does not mean you have to do anything about it.
But you may say- “Well I do have a tear of my meniscus, why shouldn’t I use my own blood to help the healing?”
Well, I agree if it is worthwhile and proven to benefit then we should attempt something. However, if the cost to you financially or otherwise, is high, you have to weight up the costs vs the benefits.
Costs vs Benefits
Muscle
Muscle injuries (namely tears & strains) have been considered as a potential condition which would benefit from PRP injections. Various authors have identified that the application of isolated growth factors to damaged tissue in animal models shows positive results. However the jump to the application of PRP as a vector for a patient’s own concentrated growth factors could potentially be a step too far. It is an attractive solution as, with the correct equipment, it is readily obtainable from the patient. Also, seeing as the World Doping Agency removed intra-muscular autologous (from the patient to the patient) platelet concentrate solutions off its banned list in 2011, it is considered fair game in elite sports. However, the scientific evidence is not there to ascertain whether the transfer of growth factor animal model studies to a human population, utilising a PRP solution, would provide any beneficial outcomes (Hamilton & Best 2011).
Ligament/ Tendon
Unfortunately, the same can be said of ligament and tendon injuries also. Human clinical trials of the therapy do not show significant benefit which would likely demonstrate a positive effect (Paoloni et al. 2011). Certainly not enough to signify a quicker return to sport in the athletic population (when compared to saline or other inert substances as a control).
Cartilage
In regards to cartilage injuries, the use of PRP injections in previous studies (although of relatively small sample size) is more encouraging. Particularly in the knee where it has been shown to possible to reduce pain and increase function (Frizziero et al. 2013). However, the mechanism behind its benefit is still being debated with the theory being less a boost to the healing process, and more due to an inhibition of inflammatory activity.
To PRP or not to PRP…?
It seems then we have little clinical proof of the ability for PRP solution injections to improve tissue healing, beyond a small number of studies which used an isolated growth factor (rather than a concentrated solution of multiple factors). Certainly if an MMA fighter comes to me with a muscle, ligament or tendon problem, I am unlikely to recommend a PRP injection just so they can fight sooner or continue with heavy training for a competition. In fact continuation of training when injured at the same intensity or volume would likely be more detrimental to the athlete.
If they presented like Maynard did, with evidence of a cartilage lesion of the knee, for example. Perhaps the use of PRP to reduce inflammation and to allow reduction in pain and improvements in biomechanical function would be beneficial. However this still must be alongside a reduction in activity and delay in full intensity training, as there is little evidence that the athlete’s healing process is superior.
Treat each injury seriously, and try to not rely on new fads of medical science until they have shown significant benefit. A delay in training and competing now, may be preferable than a career ending injury because you came back too quickly.
Stay Health & Keep Fighting
Chris @allpowersphysio
Source:Frizziero A, Gianotti E, Oliva F, Masiero S, Maffulli N (2013) Autologous conditioned serum for the treatment of osteoarthritis and other possible applications in musculoskeletal disorders. British Medical Bulletin. 105, 169-184Kaplan LD, Schurhoff MR, Selesnick H, Thorpe M, Uribe JW (2005) Magnetic resonance imaging of the knee in asymptomatic professional basketball players. Arthroscopy. 21 (5): 557-561GlobalData (2010) Platelet rich plasma: a market snapshot. http://www.docstoc.com/docs/47503668/Platelet-Rich-Plasma-A-Market-Snapshot.Hamilton BH & Best TM (2011) Platelet-Enriched Plasma and Muscle Strain Injuries: Challenges Imposed by the Burden of Proof. Clin J Sport Med. 21: 31–36Maffulli N (2013) Autologous blood products in musculoskeletal Medicine: Although they are trendy money spinners, best evidence shows little effectiveness. BMJ, 346:f2979Marx RE (2004). “Platelet-rich plasma: evidence to support its use”. Journal of Oral and Maxillofacial Surgery. 62 (4): 489–96Paoloni J, De Vos RJ, Hamilton BH, Murrell GAC, Orchard J (2011) Platelet-Rich Plasma Treatment for Ligament and Tendon Injuries. Clin J Sports Med. 21, 37-45
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