Lindsay Vonn Olympics, Leg Injury and Platelet Rich Plasma

 

Olympian Lindsay Vonn apparently has a deep bruise to the muscle on her leg.  No one knows the details of the injury or how it is being treated but it sounds like it may be a good application for platelet rich plasma.  There is NO data suggesting PRP would help her other than accelerating her healing and obviously she has little or no time left before competition.

Does anyone out there have any comments on it would be a good idea to treat her with PRP?

Therapeutic Use Exemption for PRP in Muscle Injuries

It has been unclear in the media and in the literature if the World Anti-Doping Agency has banned platelet rich plasma for intramuscular injection.  There is a need to better understand their position.

Via BloodCure sources, we have definitely determined that PRP is LEGAL to be used via the intramuscular route with a therapeutic use exemption, also known as a TUE.  To my knowledge there is NO data suggesting PRP is anabolic for skeletal muscle injuries in humans.  If there is any specific data out there please post it here.

Athletes of all kinds need to know PRP may be an option for them if they apply for the appropriate exemption.  As always, check with the governing body of your chosen sport and consult with your physicians to best determine if it is appropriate.

AM
Total Tendon

PRP beats Cortisone for Tennis Elbow in Level One Study

Under the direction of Dr. Taco Gosens from the Netherlands, a prospective, randomized, controlled trial of 100 patients was done to evaluate the efficacy of platelet rich plasma against cortisone for chronic tennis elbow.   They recently reported their results in the American Journal of Sports Medicine.  (Feb. 2010)

73% of the PRP treated patients were successful compared to 51% in the corticosteroid group (p < 0.001) at one year of follow up according to visual analog pain and functional scores.   This represents a 43% better success rate for PRP.    This data should put to end the option of using cortisone for chronic tennis elbow.  There is only limited support for its use in short term pain relief.  It is also clear from these last two papers that the evaluation of PRP must be done by specific clinical problem and the severity of the problem.  Only by doing careful studies we will be better able to predict which patients will respond to PRP as a therapy. 

Finally, PRP in my opinion should be reserved for patients that have failed non-operative treatment and are considering surgery.  Most patients with tendinopathy will respond without invasive intervention.  A study directly comparing PRP to surgical outcomes for tendinopathy should be considered.

AM
Total Tendon

Platelet Rich Plasma JAMA Article

A recently published article by de Vos et al in JAMA has resulted in a flurry of lay press articles declaring platelet rich plasma (PRP) does not work.  Much like the overhype of PRP after Hines Ward was treated just before the Super Bowl last year, this declaration cannot be defended.

In their study, patients with MODERATE achilles tendinopathy did not do better with PRP compared to saline controls.  All patients received eccentric strengthening exercises.  Their data does support the conclusion that PRP is not better than saline but ONLY for moderate tendinopathy (as measured clinically, no imaging data was reported) at six months of follow up.    The authors stated they will be following those patients for a year.  If for some reason, the PRP patients continue to improve and the saline ones do not, there could be a difference at one year.  However, the conclusion could then only be made that PRP works for MODERATE achilles tendinopathy not any other clinical entity.  Patients with SEVERE tendinopathy that has failed eccentric training was not tested in this study.

The authors need to be recognized for completing this study as we need more level one evidence like it to best define how to use PRP.  Soon, we will have more published literature to discuss. 

We still need to define the optimal formulation and dosage of PRP.  No data was collected on the patients with regard to what was actually put into the patient in terms of total platelet concentration and or white blood cell concentration.  Importantly, we also need a better understanding of the mechanisms behind PRP.

Platelet Rich Plasma Story on CNN

Anderson Cooper and Dr. Sanjay Gupta reported last night on AC360 about platelet rich plasma.  Their description of the process and potential benefits of the PRP will help patients better understand how the treatment works.  They also discuss how PRP was used by Tiger Woods and how his doctor is under investigation.  See the video below for details.  AM (Total Tendon)

Tiger Woods and Platelet Rich Plasma

Many news outlets have reported Tiger Woods was treated with Platelet Rich Plasma (PRP) after his anterior crucitate ligament surgery.  There have been no reported details but it may be reasonable to use PRP if he developed patellar tendonitis post operatively.  It must be mentioned that PRP has never been associated with any specific performance enhancement.  The use of PRP to treat tendonitis now has significant basic science and clinical support.

The stories center around a physician who treated Woods.  The physician is being investigated for a variety of illegal activites.  See the links below for details. 

New York Times Article
Associated Press Story

PRP and Ultrasound

Using ultrasound to guide platelet rich plasma injections is becoming more popular. For some indications it may be crucial. Importantly, ultrasound may an excellent way to test the value of platelet rich plasma for tendon related injuries and disorders. In the following study, Bosch et al did just that. The researchers confirmed the value of ultrasound and also found PRP treated cases had better tissue alignment.

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Total Tendon
HalfDome.TV

"The effectiveness of new therapies to treat tendon injuries is difficult to determine and is often based on semi-quantitative methods, such as grey level analysis of ultrasonographic images or subjective pain scores. The alternatives are costly and long-lasting end-stage studies using experimental animals. In this study, a method of ultrasonographic tissue characterisation (UTC), using mathematical analysis of contiguous transverse ultrasonographic images, was used for intra-vital monitoring of the healing trajectory of standardised tendon lesions treated with platelet rich plasma (PRP) or placebo. Using UTC it was possible to detect significant differences between the groups in the various phases of repair. At end stage, over 80% of pixels showed correct alignment in the PRP group, compared with just over 60% in the placebo group (P<0.05). UTC also showed significant differences in the course of the healing process between PRP treated and placebo treated animals throughout the experiment. It was concluded that computerised analysis of ultrasonographic images is an excellent tool for objective longitudinal monitoring of the effects of treatments for superficial digital flexor tendon lesions in horses."

AM

PRP Enhances Tendon Vascularity

Platelet rich plasma is now being used worldwide for tendon related injuries and disorders. Increased vascularity is one of the proposed mechanism of action for PRP. In the study outlined below, this hypothesis is supported in an achilles tendon injury model.

The poor vascularity of tendons is a major factor in their limited healing capacity. The aim of this study was to assess the effect of Platelet Rich Plasma (PRP) on angiogenesis during tendon healing. MATERIALS AND METHODS: Forty-eight skeletally mature New Zealand White rabbits were used. The Achilles tendon was transected transversely and 0.5 ml of PRP was injected into the tendon mass on each side of the incision on both limbs. The injection in the control group consisted of saline. Six animals from each group (12 tendons each) were sacrificed after 1, 2, 3, and 4 weeks following treatment. Three sections from each Achilles were stained with hematoxylinosin for microscopic examination. Further three sections were immunostained with a monoclonal antibody against CD31 (Daco Co), followed by image analysis to count new vessel numbers and statistical analysis was performed. RESULTS: There was significantly more angiogenesis in the PRP group compared to the control group during the first two weeks of the healing process, i.e., inflammatory and proliferative phase (p <> Lyras et al.

AM

Platelet Rich Plasma and ACL Surgery

The use of Platelet Rich Plasma to augment anterior cruciate ligament reconstruction has been much discussed but not well studied until now. In a prospective randomized trial, Nin et al studied allograft ACL surgery with and without PRP.

"We prospectively randomized 100 patients undergoing arthroscopic patellar tendon allograft ACL reconstruction to a group in whom platelet-enriched gel was used (n = 50) and a non-gel group (n = 50). The platelet concentration was 837 x 10(3)/mm(3), and the gel was introduced inside the graft and the tibial tunnel. The use of PDGF, on the graft and inside the tibial tunnel, in patients treated with bone-patellar tendon-bone allografts has no discernable clinical or biomechanical effect at 2 years' follow-up." Read Full Abstract

This is a good example of where PRP may NOT be helpful.

AM
Total Tendon

DNA Vaccines

DNA vaccines arose out of failed genetic engineering experiments. In this so called third generation vaccine, a piece of DNA is designed to have a cell express a specific surface antigen. It is then injected and the immune systems responds. DNA vaccines are under development for a variety of diseases including the H1N1 virus also known as the swine flu.


AM
Total Tendon

Stem Cells Improve Heart Function

Study Shows Benefits of Adult Stem Cells for Heart Disease

"In the 12-month Phase II, double-blind trial, subjects' own purified stem cells, called CD34+ cells, were injected into their hearts in an effort to spur the growth of small blood vessels that make up the microcirculation of the heart muscle....

The largest national stem cell study for heart disease showed the first evidence that transplanting a potent form of adult stem cells into the heart muscle of subjects with severe angina results in less pain and an improved ability to walk."

Read Full Article.

This is well done and interesting investigation into how your own body's cells can improve function in tissue that was once thought not to be able to regenerate. As we investigate deeper into stem cells and other treatments, we are likely to continue to challenge many long held beliefs about human physiology.

AM
Total Tendon