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.”
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.
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.
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.
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.
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.
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.
“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.
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.”
To contact the editor responsible for this story: Reg Gale at firstname.lastname@example.org.