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Glenn D. Braunstein, M.D.

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A Time-Out to Ponder If Duffers Should be Awed by Therapies Considered Game-Changers by Elite Athletes

Posted: 07/06/2012 2:16 pm

When the finely honed bodies of elite athletes break down, these players' compulsion to get back in the game sometimes can lead them to embrace medical procedures that eventually may benefit the duffers among us and more.

Athletes possess wealth and an access to resources, as well as a personal willingness to be trailblazers not just on the field or the court but also in operating rooms and laboratories, undergoing therapies to address their play-related woes.

Would we be learning as much and see such a spotlight on concussions and brain injuries, especially involving the young, if not for the athletic stars suffering head trauma on the gridiron, in the hockey rink or boxing ring? (I've written about this topic, with due warnings for care: click here.) How far would we have advanced in our knowledge of their toxicity had not so many players gotten involved with steroid use?

Without athletes like legendary pitcher Tommy John willing to press boundaries, it's arguable about where we'd be in our successful treatment of certain joint ailments. John, of course, was the first person to have ulnar collateral ligament reconstruction (or UCL) to reconstruct his pitching arm, now a common procedure in which the medial elbow tendon is replaced with a tendon from another part of the body, such as a hamstring.

Neither, I suspect, would weekend warriors be as familiar with or willing to undergo knee, wrist and ankle repairs -- nor would those procedures have advanced so far -- without the likes of Broadway Joe Namath or Olympic marathoner Joan Benoit, who won a gold medal just months after undergoing arthroscopic surgery on her right knee.

If towering sorts like Laker Andrew Bynum are willing to have their bum knees drained, why wouldn't a Baby Boomer mom who climbs four flights of stairs to her office to keep fit?

The In-Demand Therapy

So far, however, the evidence is less clear for the sporting world's latest press on the frontiers of medical science -- procedures that purport to take advantage of increased knowledge about cellular function, stem cells and the regenerative capacity of many tissues.

Pro athletes are clamoring for medical treatments such as Orthokine or Regenokine, platelet-rich plasma (PRP) and stem cell therapies, promoted to speed healing of common sports injuries like tendon tears, muscle sprains and bone fractures.

The reported A-list fans of these treatments include Laker superstar Kobe Bryant, Yankee third basemen Alex Rodriguez, Super Bowl winning Pittsburg Steelers Hines Ward and Troy Polamalu (a onetime USC Trojan), at least five Los Angeles Dodgers, 20 major league soccer players and a champion racehorse from New Zealand named Carabella.

With a prominent rush like this for such care, it's no wonder weekend warriors also now are asking about these treatments; in the case of platelet-rich plasma or PRP, which is readily available, they're not just asking, they're paying hundreds to thousands of dollars for the procedure, according to media reports.


Weekend Warriors and PRP

PRP, its advocates say, is a substance derived from a patient's own blood, which is processed to contain a high concentration of platelets. In case you missed that ninth-grade biology lecture, platelets are irregular-shaped, colorless bodies that help clot blood and stop bleeding. They also contain proteins called growth factors that aid in healing wounds and damaged tissue.

The procedure is quick and simple. A small amount of blood is drawn from the patient's arm, then spun at high-speed in a filtration system or centrifuge to separate the platelet-rich plasma from the heavy red blood cells, which sink to the bottom. PRP, a yellowish fluid, is then injected into the injured area, sometimes with ultrasound guidance. The theory goes that this super-charge of growth factors will jump-start the healing process.

PRP isn't new. It's been used since the 1980s in dentistry to aid tissue recovery after periodontal surgery, in maxillofacial surgery (head, neck, face and jaws) and to help heal skin ulcers.

Only in the last few years, however, has PRP been adopted to treat musculoskeletal sports injuries. Interest in it was piqued when it was shown to accelerate the healing of tendon and tissue lesions surgically created in animals. Of course, many therapies work in lab animals but not in humans. Given that standard treatments for musculoskeletal injuries and conditions -- surgery or physical therapy, for example -- can take months to work or sometimes never do, elite athletes have shown the willingness to test and take risks with this therapy. Its advocates say that because PRP uses the patient's own blood, the procedure minimizes risks of rejection or allergic reaction.There's always a possibility of infection whenever the protective skin barrier is breached -- and, indeed, media have reported that Toronto Blue Jay pitcher Jesse Litsch suffered an infection after receiving a PRP injection in his right shoulder.)

Grabbing bigger headlines, Ward and Polamalu's use of PRP before winning Super Bowl XLIII in 2009 led to demand for the treatment from recreational jocks. Now thousands of doctors and some 500 hospitals offer injections at $500 to $1,000 a pop, a cost not usually covered by insurance.

Meantime, while patients may be plentiful, clinical validation for the procedure is not. There have been no large, rigorous trials. Scientific research on the effectiveness of PRP in treating musculoskeletal injuries is limited and reflects the slippery measure of patients' perception of pain.The placebo effect is powerful among motivated patients in search of a remedy.

One of the most stringent research efforts, so far, a double blind study conducted in the Netherlands, concluded that PRP was no better than a salt-water placebo in treating Achilles' tendons. After six-month and one-year follow-ups, researchers found no significant difference in pain level between the 27 individuals who received saline injections and those who given PRP.

British researchers also concluded that PRP was no more, and possibly less effective, than injections of whole blood in treating tennis elbow.

At the same time, there have been encouraging findings, too. Among these, a just released pilot study of 120 patients with knee osteoarthritis, the same ailment as reportedly experienced by Kobe Bryant, found PRP significantly better than hyaluronic acid, a commonly used lubricator, at three- and six-months after treatment.

Another study, also conducted in the Netherlands, involved 100 patients with chronic tennis elbow. Among the group that randomly received PRP treatment, 73 percent reported significant improvement, compared to only 51 percent of those who received corticosteroids.

Contradictory results may in part be due to a poor design of the of treatment protocols and the relatively low number of patients in the trials. Also, preparation of the PRP varies in different studies, with the concentration of platelets ranging from double to three- to 10-times the amount of platelets found in normal blood. Other differences include the volume and frequency of injections and mechanism of platelet activation.

Bryant and Rodriguez, according to media reports, traveled to Germany for a treatment called Regenokine therapy, which is similar to PRP but with distinct differences. Among the biggest is that in Regenokine, a patented procedure created by a physician in Dusseldorf, the blood is incubated at a slightly elevated temperature before it is spun and later injected.

Like PRP therapy, there's an absence of rigorous clinical trials on Regenokine (also called Orthokine) and its effectivenees. Bryant's stellar post-Regenokine season, however, is all the proof teammate Bynum needed, the media reported, to skip this summer's Olympics and instead jet to Germany to undergo this therapy.

Aside from Bryant's performance, the best support for this therapy comes from a study of 376 patients with knee osteoarthritis.The treatment reduced pain symptoms for 67 percent of those who received it, compared to just 32 percent of those who got either saline or hyaluronic acid.

In the United States FDA regulations state that blood and tissue may only be "minimally manipulated." More than that constitutes the creation of a new drug that would require FDA approval. While that language may seem loose and open, most American doctors aren't willing to tempt the ire of regulators.

Regenokine isn't the only treatment that has professional athletes logging frequent flier miles. Instead of relying on the relatively small number of stem cells that swim in blood, cellular "scientists" elsewhere in the world are extracting millions more out of bone marrow and fat, and then engineering them into what some term injury-fighting miracle workers.

Quarterback Peyton Manning (once of the Indianpolis Colts and now the Denver Broncos), according to media reports, traveled to Europe for a stem cell treatment to fix problems caused by a bulging disc. NFL wide receiver Terrell Owens is said to have traveled to South Korea for similar treatment for a knee injury.

Only time and rigorous clinical study will tell whether Kobe, A-Rod and the others have found bona fide beneficial therapies or merely another faux fad among athletes, who have popularized at various times such eyebrow-raising health trends as titanium necklaces or oxygen chambers. For those who aren't prolonging six- and seven-figure athletic careers and whose interest is focused mainly on maintaining the fun of pitching for the company softball team, running weekend 5K races or kicking around a soccer ball with the kids, common sense about your athletic limits and keeping fit will go a long way to keeping away the need for extreme therapies. These provide great fodder for the sports pages but until researchers, physicians and more ordinary patients prove such treatments' value in factual, scientific fashion, we all should just, as the popular metaphor says, be sure we don't get out over our skis.

 
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