Monday, July 17, 2017

Considering PRP (Platelet Rich Plasma) or Stem Cell Injection?

Some days, swim practice just seems too hard; that you'd rather be on this side of the pool with your seahorse life ring. It does get better though.

Stem Cells and Platelet Rich Plasma

Whether or not the current enthusiasm shown by some in the emerging biologic choices in the treatment of musculoskeletal injuries, arthritis and the like is justified is really not yet clear. I'm speaking predominantly of PRP, platelet rich plasma and MSC, mesenchymal stem cells.  According to the Mayo Clinic, "over 600 stem cell clinics in the US offer one form of stem cell therapy or another, to an estimated 100,000-plus patients who pay thousands of dollars out of pocket, for the treatment, which has not undergone demanding clinical study."

I must say it's an attractive concept though, to use these, non-operative, in-office, minimally painful, almost sexy procedures to, as the web ads would have you believe to:

"Get you back to doing the things you love, faster and without surgery,"or

"combine proprietary biologic cellular therapies with state-of-the-art orthopedic interventions to postpone or eliminate the need for surgery," or

"If you've encountered an injury to the knee meniscus, cartilage, ACL or MCL ligaments, or have chronic knee pain due a past injury or arthritis, you may be a good candidate for knee stem cell therapy or platelet rich plasma procedures."

And then they show you pictures of people who are younger than you, possibly more athletic than you, certainly have a better golf handicap than you and more closely resemble movie stars than you, who are having this same treatment.

Too good to be true?  Probably.  If you're a regular reader of this blog, you know that I'm a fan of Paul Offit, MD, the chief of the Division of Infectious Diseases (a big deal!) at Children's Hospital of Philadelphia, and have used this quote previously.  This just seemed to be a perfect place for it.   He wrote about whether or not health food stores, wonderlands of promise, who sell 54,000 kinds of supplements, do what they say they will noting that if people want to burn fat, detoxify livers, shrink prostates, avoid colds, stimulate brains, boost energy, prevent cancer, extend lives, enliven sex, "all they have to do is walk in."

But those of us who suffer pain or distress from tendonitis, arthritis, or any number of   musculoskeletal maladies which seem incurable at the time, are a susceptible audience. The idea that these treatments can put us back on the road or in the pool are terribly attractive, right?

One of the big problems so far is that although there are a "prodigious number of clinical trials" in the literature where a host of different conditions have been addressed with PRP or MSC, according to Iain R. Murray in the prime journal of the orthopedic community, the Journal of Bone and Joint Surgery.  Those published to date "have failed to include sufficient experimental detail" to make replication by others possible.  These are complex procedures with a wide variety of "preparation methods, protocols and methods of delivery."  After an extensive period of research, and several rounds of surveys, 24 experts in the field established a consensus statement and a 23 item checklist for PRP, and a 25 item check list for those wishing to publish their results on treating patients with MSC.

What does this mean to you?  Well first off, this is an area of treatment with tremendous possibilities but there is still much to learn.  We as a medical community need to standardize and optimize our understanding of the biology of both the disease and the treatment. This is due in part from a study in the American Journal of Sports Medicine where arthritic participants were injected in both knees, one with MSC and one with just plain saline, but neither they nor the doctor knew which was which.  They had "dramatic improvement" in both knees.  So does that mean you can inject basically whatever you feel like into an arthritic knee and it will improve?  Obviously we have much to learn.  They were able to conclude from the study that the procedure was safe but that further research is necessary, following the checklists above, before the procedure is deemed effective and becomes adopted nationwide and employed in a routine fashion.  That said, as noted above, there are 100's of clinics standing by to accept your payment for a treatment tomorrow.

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