It appears as if Nadal has had his creaky knees treated with platelet rich plasma. He has described it himself but only incompletely. What we do not know is what type of PRP was used, how it was injected and how he is being treated after the procedure. These are all critical issues. Presently, PRP with platelet concentrations around 5x baseline combined with concentrated white blood cells has the best published data supporting its use.
It is clear that Nadal has chronic, severe tendonitis also know as tendinopathy. It will help all of us who are studying how to best use PRP we knew more about his specific treatment. Does anyone out there know any of the details?
AM
Total Tendon
16 comments:
Dear Dr. Mishra
I have just read with surprise the text published in your blog this Sunday about the use of platelet rich plasma in one of my patients, since all the questions that you ask are answered by us in the literature.
First of all, a blog might not be the ideal setting to talk about a patient´s illness. From an ethical point of view I consider that without the patient´s permission we are not allowed to reveal diagnosis, nor applied treatments or prognoses.
As you probable are aware, we have been working with plasma rich in growth factors (PRGF®), the pioneer in autologous technologies, for more than a decade. Our first publication dates back to 2003 and PRGF® is one of the products, if not the product, that has been characterized more extensively in the literature, both clinically and biologically. It is also the most versatile, being used with success in many medical fields. You will be able to find in Medline numerous articles published by our investigation group.
Regarding the controversy and speculation around plasma rich products I find it necessary, once again, to differentiate between the existing PRPs. More than 60 international articles of high relevance have shown that the PRGF® technology is safe and effective in accelerating wound healing and tissue regeneration. Our results in the laboratory, with experimental animals and in the clinical setting have demonstrated the therapeutic potential of this product.
PRGF® has a moderate concentration of platelets (around x2-3 above baseline), it is activated exclusively with calcium and it DOES NOT contain leukocytes (the buffy coat) as it would increase inflammation and would not provide additional positive effects from a biological point of view.
The treatment for chronic tendinopathies is fully described by us in the literature. The use of the ultrasound scan is indispensable…
I would have been happy to answer all your questions directly and not through a blog. I am at your disposal should you require any additional information.
Sincerely,
Mikel Sánchez, MD
Dear Dr. Sanchez,
While I agree that it wouldn't be right to discuss the treatment received by one of your athletes, I'm wondering if you could discuss specifically what steps are being taken to monitor the procedure and ensure it is being performed in conjunction with the drug testing regulations, since it reportedly has a potential for performance enhancing drug use (and, of course, there was the recent scandal involving another practitioner of the therapy, Tony Galea, who also seemed to focus his practice exclusively on highly paid professional athletes who are subject to drug testing). There are also numerous independent studies which do not seem to show it as an effective treatment, as I'm sure you are aware. Since there are many rumors about the possible performance enhancing drug use of your client, I'm sure you can see where there is potential for suspicion as to the exact nature of the therapy. Are there any representatives of drug testing agencies who monitor these treatments when you are performing them on professional athletes subject to drug testing? Assuming that you are doing nothing outside of the rules, I'm sure you would want to maintain transparency when performing such a procedure on an athlete like Rafael Nadal.
Dear Drs. Mishra and Sánchez,
What is your reaction to this recent article?
JAMA. 2010 Jan 13;303(2):144-9.
Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy
Context Tendon disorders comprise 30% to 50% of all activity-related injuries; chronic degenerative tendon disorders (tendinopathy) occur frequently and are difficult to treat. Tendon regeneration might be improved by injecting platelet-rich plasma (PRP), an increasingly used treatment for releasing growth factors into the degenerative tendon.
Objective To examine whether a PRP injection would improve outcome in chronic midportion Achilles tendinopathy.
Intervention Eccentric exercises (usual care) with either a PRP injection (PRP group) or saline injection (placebo group). Randomization was stratified by activity level.
Conclusion Among patients with chronic Achilles tendinopathy who were treated with eccentric exercises, a PRP injection compared with a saline injection did not result in greater improvement in pain and activity.
http://www.ncbi.nlm.nih.gov/pubmed/20068208
I'm particularly interested in the response by Dr. Sánchez as I believe you hold some patents with respect to PRP treatments.
Dear Dr. Mishra,
As I mentioned, a blog is not the setting to discuss all these medical issues. We will be pleased to answer all your questions related to this case in private. Could you provide us with an email address we could write you to?
If you prefer not to, you can email us at:
mikel.sanchez@usphospitales.com
Sincerely,
Dr. Mikel Sánchez
Dr. Sanchez,
I'm not sure why you would consider it inappropriate to respond to the above commenter's question in "a blog." It seems that some of the independent studies are not showing much benefit from the treatment. Since many of the studies showing benefit are primary authored by you, and you are receiving a great deal of public notoriety and, no doubt, remuneration for this procedure, I would think that you would want to defend the efficacy of the treatment when the most recent study seems to show that it is no better than an injection of salt water. It's hard to accept the idea that you are trying to be discrete when a quick google search of this treatment shows your name attached not only to many studies of the procedure, but to sports celebrities you are treating with the procedure.
If you would like to e-mail me, my address is:
tennisroids@gmail.com
Dr. Sanchez,
Perhaps you would be willing to offer an opinion on this recent journal article?
Br J Sports Med 2010;44:616-617 doi:10.1136/bjsm.2010.074138
Editorial
Muscle injuries and PRP: what does the science say?
"Studies in human muscle injury are few and of low methodical quality. Wright-Carpenter et al treated 18 professional sportsmen with a variety of muscle strains with ACS and reported improved healing by almost a week compared with a similar group of 11 professional athletes.17 The numbers in this study are small, the muscle strains are heterogenous, and there was no true ‘control’ group, as the ‘control group’ had been treated with Traumeel S and Actovegin, and was reviewed, retrospectively. Sanchez reported in a poster presentation a case series of 20 professional athletes with hamstring muscle injuries who received PRP therapy that functional recovery was regained in half the expected time, but we have found no peer-reviewed publication from this poster (Sanchez 2005)."
Br J Sports Med 2010;44:618-619 doi:10.1136/bjsm.2009.067108
Editorial
Platelet-rich plasma: any substance into it?
"...the sceptics point out that, given the well concerted healing cascade that has evolved over millions of years, it is not easy to understand how a single or even a few injections of a cock tail of growth factors at variable, and at
present not well codified, times from the injury will produce a lasting beneficial effect on a wide variety of conditions.
"The aim of PRP injections is to achieve predictable and fast tissue repair through a new well-organised extracellular matrix, which ideally would reach the high mechanical performance and functional levels of native tissue in the shortest time possible. Despite the hype of the technique and its biological plausibility, the anecdotal nearly miraculous recovery reported in the lay press in some famous athletes, and the myriad of extremely favourable retrospective and prospective studies published, level I investigations are lacking. We prompt researchers to undertake appropriately powered level I studies with adequate and relevant outcome measures and clinically appropriate follow up."
http://bjsm.bmj.com/content/44/9/618.extract
Dear friend,
The Aquiles tendinopathy is a chronic degenerative injury that may not be successfully treated with just one dose of any treatment. In fact, in our animal studies we have evidenced that optimal results are seen when several infiltrations with PRGF® are performed.
In our opinion a chronic tendinopathy must be treated with two or three consecutive infiltrations. The JAMA paper is methodologically perfect but they treat a chronic illness with just one dose of a PRP that concentrates leukocytes.
The conclusions drawn from this study can lead to misinterpretation of the results.
Sincerely yours,
Dr. Mikel Sánchez
We use this treatment in all kinds of patients and also in athletes. We are very well aware of the anti-doping regulations. About a month ago, we were invited to join a committee of 20 medical experts in Lausanne to study the different applications of this treatment under the tutelage of the IOC and the WADA.
PRPs cannot be used in muscle injuries, but its use in tendinopathies is allowed after completing a TUE (Therapeutic Use Exemption) document. In fact, some representatives of the spanish anti-doping agency and the spanish olympic committee visited Dr. Eduardo Anitua´s research center in Vitoria, and granted us permission to use this treatment in this particular athlete.
I insist on the fact that the PRGF® is the best characterized PRP in the literature. I really don´t see how, from a scientific point of view, several infiltrations inside the tendon of an athlete can enhance performance. Maybe ignorance can lead to this conclusion.
Our protocols in the treatment of tendinopathies are sufficiently published in the literature. We would like people to be more cautious when mentioning doping subliminally. It is a very severe accusation to be made thoughtlessly. It is surprising to see how easy rumors and propaganda in non-specialized press cast a shadow of doubt over our medical practice.
We are present in every scientific forum we are invited to but we never argue or comment on our patient´s medical records without their consent.
With this letter we want to put and end to our participation in this discussion. We are at your disposal should any colleague require any additional information about our use of PRGF® in different pathologies.
Please send your questions to: mikelsanchez@ucaorthopedics.com
Sincerely,
Dr. Mikel Sánchez
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