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Healthcare Journal of Baton Rouge
|March / April 2010 Issue
and the only way we’ll know is through further studies.
“However, when we do surgery we are cutting out that dis-
eased tendon. The surgery itself causes an inflammatory
response, which is going to increase blood flow to that area. If
we can inject something that will increase the growth of new
blood vessels it seems logical to me that this has a real
chance of solving the problem.” While he and his colleagues
have used the therapy, Laughlin said PRP, “hasn’t so far,
passed the test of time and there’s no double-blinded studies
out there.” However, he indicated that doctors often use ther-
apies that seem to work before the scientific studies that sup-
port them are in place. “That’s very usual for the way medical
advances come along,” said Laughlin, pointing to the high cost
of doing the studies. “I’ve heard that to run a very good dou-
ble-blinded study can cost between $5 million and $10 million
and you need a statistically significant group of patients.” In
the meantime, doctors are seeing some promising results so
they are giving it a try. Treatments like these can also be driv-
en by public demand and given recent articles about PRP’s
use in professional athletes, patients may start to ask about it
although, “I haven’t had anybody personally come to me and
say, “I want some platelet rich plasma,” said Laughlin.
Instead, PRP is generally only offered to patients who have
chronic conditions, have exhausted other options first, and are
considering surgery. “If a patient comes to me with tennis
elbow, even if they’ve had it for four months, I give them a cor-
tisone shot first,” said Broyles. “A lot of times patients will get
better with that…it’s a quick fix, they get immediate relief and
if it goes away then fine.” Broyles has also had patients opt for
surgery rather than a single PRP injection. That may or may
not surprise you depending on how familiar you are with the
vagaries of insurance coverage. Because PRP therapy is still
relatively unknown and lacking large, long-term, randomized
studies to back its efficacy, some insurance companies won’t
cover the treatment. However, orthopaedic surgery to correct
a chronic condition generally is covered. If insurance won’t
cover the treatment, Broyles charges $500 per PRP proce-
dure. Based on reports from around the country, PRP therapy
can cost as little as $150 to as much as $2000 per shot. It’s a
significant cost, but may still
be less than many patients’
deductibles and is certainly
less invasive than surgery.
Laughlin said some of the
doctors at his clinic only use
PRP during surgery because
the cost is more likely to be
covered. It can be used to
reduce bleeding and promote
healing during rotator cuff
repair or knee replacement.
It may also come as no sur-
prise that any procedure that involves talk of growth factors
and professional athletes has drawn close scrutiny. “I’ve seen
that question come up before and in my opinion as a physician
and knowing what this is, I don’t think there should be any
controversy about the use of this in athletes,” said Broyles. “If
you were to ban this you would have to ban any other inter-
vention that we do for athletes including therapy, including sur-
gery. Surgery is much more invasive than this–we’re changing
the natural course of events–this is simply giving the patient
his own platelets.” He said there should be no suspicion
because the only thing that’s added is an anticoagulant to
keep the blood from clotting when you spin it down. It is not
enhancing performance, just healing. “I guess that’s a way to
look at it,” said Dr. Laughlin who indicated that the Olympic
sports committees, particularly the World Anti-doping Agency,
have not approved PRP for use in athletes because it is a
blood product that is helping something heal outside of the
ordinary process. “From the Olympics’ perspective, the big,
rich countries would have an added advantage over other
countries that don’t have this therapy available,” he said.
Laughlin said that while the evidence supporting PRP is bet-
ter than anecdotal, it’s still a technique looking for definite indi-
cations. “Nobody knows if we should do it after they’ve had the
pain for three months or six months. How deep do we inject it?
What we really need is double-blinded, controlled studies. In a
perfect world we would have evidence-based medicine for
everything that we do.” While Broyles agrees the studies are
needed, he thinks PRP is a promising technology. “I think
twenty years from now or maybe before that, we won’t be
doing surgery for tendonosis. And it may not be platelets we’re
using. It may be that we have a vial of endothelial growth fac-
tor that you order from the pharmaceutical company that we
inject directly into the tendon.” In the meantime, blood is all
you need.
v
Sources: Robert J. de Vos, MD, Adam Weir, MBBS, Hans T. M. van Schie, DVM, PhD, Sita M. A.
Bierma-Zeinstra, PhD, Jan A. N. Verhaar, MD, PhD, Harrie Weinans, PhD, Johannes L. Tol, MD,
PhD, “Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy,”
JAMA
.2010;303(2):144-
149; Storrs, Carina, “Is Platelet-Rich Plasma an Effective Healing Therapy?”
Scientific American,
Dec. 18, 2009 http://www.scientificamerican.com/article.cfm?id=platelet-rich-plasma-therapy-den-
nis-cardone-sports-medicine-injury; Schwarz, Alan, “A Promising Treatment for Athletes, in Blood”
New York Times
, Feb 16, 2009, www.nytimes.com/2009/02/17/sports/17blood.html; Hall, Michael,
MD, Band, Philip, PhD, Meislin, Robert J., MD, Jazrawi, Laith, MD, Dardone, Dennis, DO, “Platelet
Rich Plasma: Current Concepts and Application in Sports Medicine,”
Journal of the American
Academy of Orthopaedic Surgeons
, October 2009, Vol. 17, No. 10. P. 602-608; Boyan, Barbara
D., PhD, Schwartz, Zvi, DMD, PhD, Patterson, Thomas E., PhD, Muschler, George, MD, “Clinical
use of platelet-rich plasma in orthopaedics,” American Academy of Orthopaedic Surgeons,
September 2007,
AAOS Now
, http://www.aaos.org/news/bulletin/sep07/research2.asp; Mishra A,
Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma.
Am J Sports
Med
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tal injuries: a review,
Curr Rev Musculokeletal Med
., DOI 10.1007/sl 2178-008-9032-5.
Nobody knows if we should
do it after they’ve had the
pain for three months or six
months. How deep do we
inject it? What we really
need is double-blinded,
controlled studies. In a per-
fect world we would have
evidence-based medicine
for everything that we do.
- joe LaughLin, md
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Healthcare Journal of Baton Rouge
| March / April 2010 Issue
Joe Laughlin, MD