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The Blood Injections That Might Transform Orthopedics

Chris Waddell has been an élite athlete for more than two decades. He has won twelve medals in downhill skiing, including five golds, in four Paralympic Games events; he was a world-record-holding wheelchair track sprinter; and, in 2009, he became the first paraplegic to climb Mt. Kilimanjaro, using his arms to power a customized four-wheeled cycle. Even at forty-five, Waddell, who was paralyzed in a college skiing accident, has a muscular, sharply defined upper body, the product of thousands of hours of training.

But all this exercise has taken a toll. Several years ago, Waddell’s shoulders began to ache constantly. Last year, he tore a rotator cuff while weightlifting, and began having trouble lifting himself into and out of his wheelchair. “I had no control,” he said. “When I was getting off a couch, I had to marshal all of my strength.”

Waddell, who lives in Park City, Utah, went through a range of treatments. “I tried a lot of rehab, I did a lot of exercises, I had a cortisone injection,” he said. “I wasn’t making any progress.” Several orthopedists told him he would have to accept being in pain for the rest of his life.

Rotator-cuff surgery seemed like Waddell’s last option. It would mean losing the use of his arms, and his ability to move on his own, for several months. And he worried that, if surgery failed, he would have to give up any strenuous physical activity. “Being able to ask a lot of my body makes me feel good,” he said. “It’s a lot of who I am.”

As Waddell considered his options, a friend suggested looking into a treatment known as platelet-rich plasma, in which doctors inject a modified version of the patient’s own blood into injured tissue. Eager to avoid surgery, Waddell flew to Washington, D.C., to see Victor Ibrahim, a sports-medicine doctor who specializes in P.R.P. Ibrahim found that Waddell had a torn rotator cuff in one shoulder and a torn biceps tendon in the other. Using ultrasound to locate the precise locations of the injuries, Ibrahim injected the tendon and rotator cuff with P.R.P. Over the course of a month, he repeated the procedure twice more.

In the weeks afterward, Waddell saw his strength improve and his pain decrease; he says he is now “close to one hundred per cent,” and is no longer thinking about surgery. “I was shocked that I kept getting better,” he said. “It had been so bad for so long.”

The outcome didn’t surprise Ibrahim, who estimates that he has treated around five thousand people with P.R.P. over the past five years. He says that the treatment can repair tendons, ligaments, cartilage, and nerves, and can even regrow tissue that has been frayed or damaged. This, he suspects, is what happened with Waddell’s rotator cuff. “For a lot of conditions, it’s almost a wonder drug,” Ibrahim told me. “We’ve figured out a way to help the body regenerate itself.”

P.R.P. sounds implausible. But credible scientists and clinicians, many from major institutions, say that it can heal a range of orthopedic injuries, which are often difficult to treat. Dozens of studies, some in cells, some in animals, and some in humans, have found that the procedure can repair chronic tendon injuries, heal damaged muscles and ligaments, and reduce arthritis pain.

Interest in P.R.P. is growing in part because traditional treatments for joint problems, such as arthritis, torn ligaments, and damaged tendons, are only marginally effective. Surgery sometimes succeeds, but it often doesn’t help and can cause further damage; cortisone shots can temporarily reduce pain, but they don’t address the underlying problem; physical therapy can be effective, but it often doesn’t work. Many people are left to limp along with ice and ibuprofen.

“Patients have been dissatisfied with what we have to offer them,” said Allan Mishra, an orthopedic surgeon at Stanford University Medical Center, who has been researching the technique and has used it on his patients for more than a decade. He thinks it will revolutionize orthopedic treatment. “Fifty years ago, getting a new knee was unimaginable,” he said. “Now it’s commonplace. This will have the same trajectory.”

The process of making P.R.P. is relatively simple. A doctor draws between half an ounce and an ounce of the patient’s blood and spins it in a centrifuge to separate the platelets, the disc-shaped cells best known for their crucial role in clotting, from most of the red and white blood cells. The spinning concentrates the platelets in the plasma, the liquid part of blood. When the process is finished, the number of platelets in the plasma increases by a factor of between two and twenty, depending on the spinning method. The substance is then injected into the site of the injury, whether it’s a ligament, a tendon, or an arthritic joint.

The treatment was first used about thirty years ago by dental surgeons, to repair jaws and other facial bones that often don’t heal well. Researchers knew that these areas have fewer blood vessels than many other parts of the body, and wondered if the healing problem was related to a lack of blood. They found that P.R.P. could improve results in these situations, as well as for wounds that were slow to heal. The side effects were generally minimal—soreness, stiffness, and swelling from the injection—so doctors were willing to try it. In the mid-nineties, veterinarians began using it to treat tendon, ligament, and cartilage injuries in horses; like bone, these tissues tend to have a relatively limited blood supply. About a decade ago, P.R.P. moved back to human orthopedics and sports medicine. Practitioners estimate that P.R.P. is now used by a few hundred doctors around the country, mostly orthopedists and sports-medicine specialists. There are no statistics on how many people have been treated, but Ibrahim and others who use P.R.P. put the number in the tens of thousands, including hundreds of élite athletes like Waddell.

At the same time, P.R.P. remains controversial. One of the leading skeptics is Stephen Weber, an orthopedic surgeon in Sacramento. Six years ago, he became interested in P.R.P. and set up a study to see if it could help patients recover from shoulder surgery more quickly. He operated on the rotator cuffs of sixty people, half of whom received a P.R.P. injection afterward. His study, which was published last year, found that P.R.P. made no difference in patients’ recovery speeds. “We need to be very cautious,” he said. “Just because a Los Angeles Laker gets it doesn’t mean that it works.”

Even some pro-P.R.P. doctors worry that marketing and hype have overtaken science. Vijay Vad, a sports-medicine specialist at the Hospital for Special Surgery, in Manhattan, uses P.R.P. in his practice and says the treatment can work especially well for tendon injuries. But he thinks some doctors are using it indiscriminately. “It has merit,” he said. “But people have gone way overboard. Some of it is a moneymaking gimmick. Medicine needs to be careful.”

As sometimes happens in medicine, doctors are offering a treatment before science has figured out how best to administer it. “We did it backwards,” said Lisa Fortier, a veterinary surgeon at Cornell and a leading researcher. “We got to clinical practice before we figured out the best methods.”

How P.R.P. works remains an open question. “To be honest, we barely understand the biology of this,” Mishra said. Platelets contain more than a thousand different proteins and hormones that stimulate cell growth and repair, such as vascular endothelial growth factor and the insulin-like growth factor-1. On their own, many of these chemicals are known for their ability to heal injury and relieve pain. Together, they may have a synergistic effect, which could explain the treatment’s power.

Given this uncertainty, it’s not surprising that there is a good deal of controversy over the best way to make P.R.P. About twenty companies make the centrifuges, and each brand produces a different blend. “P.R.P. is not P.R.P. is not P.R.P.,” said Martha Murray, an assistant professor of orthopedic surgery at Harvard Medical School who has been studying the how the treatment works in ligament injuries. Probably the most heated debate is over white blood cells. Depending on how it is processed, P.R.P. can contain hundreds of white cells or almost none. These cells are part of the immune system; to discourage infection and remove damaged tissue, they cause inflammation at the site of an injury.

Some doctors and researchers, including Fortier and Ibrahim, argue that P.R.P. should contain few white cells, because the inflammation impedes healing. But another faction argues that white cells are crucial for repair. Some doctors even tell their patients to stop taking anti-inflammatory medicines, such as aspirin or ibuprofen, a few days before treatment, to ensure that nothing inhibits the post-injection tenderness and swelling.

Both sides may be right, according to Mishra and other researchers. For chronic tendon injuries, which involve scarring and degeneration but no inflamed tissue, a mixture that triggers inflammation may spark healing; for arthritis, in which damaged cartilage is already inflamed, a version with few white cells could be more effective. “We’re still trying to figure out what the best recipe is for each condition,” said Fortier.

For the past five years, she has collaborated on research with several prominent human orthopedists, including Brian Cole, an orthopedic surgeon at Rush University Medical Center, in Chicago, and a team doctor for the Chicago Bulls and the Chicago White Sox. Together they are examining several issues, including whether P.R.P. can do more if it stays in contact with the injury for longer. To increase its stickiness, they and other research groups are experimenting with fat, collagen, and fibrin, a protein that helps clot blood.

In part because of the many uncertainties surrounding P.R.P., insurance companies rarely cover the treatment, which can be expensive; a single injection costs between five hundred and two thousand dollars, depending on the doctor and the amount of blood needed. Most patients get two or three injections. The University of Pittsburgh orthopedic surgeon James Bradley, who does research on P.R.P. and uses it in his practice, understands insurers’ hesitation. “They’re not going to pay for it until we have really concrete evidence,” he said.

That evidence may not arrive soon. Many positive P.R.P. studies have been published in recent years, but none were large human trials with thousands of subjects—the sort of research that typically persuades insurance companies to change reimbursement policies—because studies such as these can cost millions of dollars, and are almost always paid for by a major drug company that wants F.D.A. approval of a patented drug. P.R.P. is not patented, and is already on the market—the F.D.A. allows the procedure, and approves the centrifuges based on whether they modify blood safely and in accordance with manufacturers’ claims. As a result, the makers of P.R.P. machines have little incentive to conduct large trials.

Despite these issues, P.R.P. continues to spread. “We do not have a perfect grasp of how to use this yet,” Mishra said. “We have a lot of work to do. But it’s beyond the promising stage. We know there is tremendous value in this.” The bottom line, he says, is that even as doctors and scientists refine it, P.R.P. is helping a lot of people.

Last month, Waddell completed a month-long, fifteen-hundred-mile cycling trip from Seattle to San Diego, raising awareness about his educational foundation along the way. Using his arms to power a custom-fitted three-wheeled bike, he rode about sixty miles a day. He says he couldn’t have done it without P.R.P. “For me, it’s been a total godsend,” he said. “I didn’t want to sit on the couch for the rest of my life.”

David Kohn writes about medicine and science. He lives in Baltimore.

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What is Frostbite and How Do I Prevent It?

An interesting article on Frostbite  from Stop Sport Injuries fall issue.  http://stopsportsinjuries.org

 

What is Frostbite and How Do I Prevent It?

by Christopher Tucker, MDAthletes participating in outdoor winter sports, such as alpine and cross-country skiing, snowboarding, and mountaineering, are at increased risk for developing frostbite. Frostbite is a condition in which prolonged exposure to cold temperatures cause an injury resulting in tissue damage— starting superficially with the skin and potentially spreading deeper to blood vessels, muscles, tendons, and even bone.

What Does Frostbite Feel Like?

Many people who are developing frostbite experience early symptoms such as numbness or a tingling sensation in the skin, such as the “pins and needles” that you can feel after a hand or foot falls asleep. The affected body part may also be extremely painful, feel itchy, or have a burning sensation. The skin can initially

appear white or grey with a surrounding area of redness, and as frostbite progresses, blisters may form and

the skin will feel hard, waxy, or numb.

Who is at Risk?

While anyone can potentially develop frostbite, both the very young and the elderly are at particularly high risk and should take special precautions to prevent over-exposure in cold environments. In addition, athletes with medical conditions such as diabetes or heart conditions can be at increased risk due to decreased blood flow to the skin.

How Cold is Too Cold?

Generally, the risk of frostbite is low when the outside temperature is above 14°F (-10°C), but that risk can go up significantly with prolonged exposure, increased elevation (>17,000 feet), and increased wind speed.1

How Do You Treat Frostbite?

Preventing injury begins with protection from the elements, which requires getting out of the cold as soon as possible and replacing all wet clothing with dry, warm, insulated layers. Immobilizing the extremity to prevent

damage to the cold, stiff skin and muscles can prevent further injury. Once inside, rewarming the affected extremity should be done rapidly by immersion in a warm water bath at 104°–107.6°F (40°–42°C) for 15 to 30 minutes until thawing is complete.1,2 If warm water is not available, body heat can be used to rewarm the hands or feet, such as tucking them in your armpits. When successful, the skin becomes soft and pinkish again. Avoid rubbing or massaging the skin to avoid damaging the skin or rupturing blisters.

An Ounce of Prevention

While outdoor winter sports provide an excellent opportunity for physical exercise and competition, they can be dangerous if athletes are not properly prepared. Useful tips to help prevent frostbite include:

Check weather forecasts to prepare for inclement weather or avoid extreme weather.

Wear adequate clothing to protect from the cold and wind—dressing in loose-fitting layers, including fabric that wicks away body moisture and sweat is best.

Cover exposed skin with gloves or mittens, a hat, scarf, and face mask, if needed.

Minimize alcohol consumption and tobacco use.

Stay active! Physical activity maintains core body temperature as well as increases blood flow to the hands and feet.

References

1. Golant A, Nord RM, Paksima N, Posner MA. Cold exposure injuries to the extremities. J Am Acad Orthop Surg. 2008;16:704-15.

2. McIntosh SE, Hamonko M, Freer L, Grissom CK, et al. Wilderness medical society practice guidelines for the prevention and treatment of frostbite. Wilderness Environ Med. 2011;22:156-66.

 

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Custom Knee Brace Article Georgian Life

Darryl Novotny BScPT, Registered Physiotherapist at Orthopaedic Sport Institute has written an article for Georgian Life December issue about custom knee bracing.

As winter looms and the ski hills are blanketed in snow, many people are reminded that their knee pain may limit, or even stop, their participation in snow-related sports.

Many individuals have been diagnosed with osteoarthritis (OA) of the knee – this is characterized by a loss of the protective cartilage at the end of each bone in your joint, usually more on one side of the knee than the other.  OA generally occurs due to gradual wear and tear of a joint over decades of physical activity, but can also be caused by an injury.

For those situations in which surgery is not yet an option, conservative treatments of OA-related conditions can include:

  • Physiotherapy: OA-symptoms are often related to joint stiffness and weakness of muscles surrounding the affected joint.  Physiotherapy treatments should be directed towards restoring as much motion and muscle strength as possible.
  • Pain relieving modalities: Regulated healthcare practitioners can provide treatments directed towards relieving the symptoms.  These options often include muscle stimulation units, laser, ultrasound and analgesic creams.
  • Oral anti-Inflammatories (NSAID’s)
  • Cortisone injections: This treatment can help many people diminish or even eliminate their symptoms for an extended period of time
  • Hyaluronic Acid (HA) injections: This involves an injection of HA directly into the joint to improve the amount of lubrication in the affected knee joint

While these interventions are sometimes successful, patients do not always experience 100% relief and, as a result, regular physical activity becomes increasingly limited and painful.  The development of Custom OA Knee Unloader braces have led to another non-invasive, drug-free solution for people suffering from knee OA.  These lightweight braces are designed to reduce pressure on the side of the knee that has worn down.  Once fitted, these braces are easy to don and, due to their low-profile build, can easily fit underneath your outdoor skiwear.

For further information on treatment options, please contact the Orthopaedic Sport Institute at (705) 467-0701 or info@ortho-sport.ca and ask for a consultation with one of our friendly healthcare professionals.  Let us help get you back onto the ski hill!

 

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Qi Gong Classes

Orthopaedic Sport Institute is offering Qi Gong classes every Saturday from 10:00am – 11:00am.  The classes will be held at 500 Ontario Street in our Gym.   Our teacher is  Dimitri Tkhinvaleli, D.O.M.P, C.H., R.M.T., C.Z.S.P., Senior Instructor at Canadian Kuo Shu Martial Arts Federation and Chung Wah Kung Fu Martial Arts (Mississauga).

 

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IN THIS COURSE YOU WILL LEARN:

The importance of self-awareness and pre-requisites of true health.  Brief history of Qi Gong.  What is Qi Gong?  Clearing misconceptions, learning about life cultivation principle.  Anatomy and Physiology of Qi Gong.  Various types of Energy.  Various Qi Gong methods, medical, martial, philosophical.  Levels of Qi Gong learning.  Importance of regular training as a major requirement to steadily growing health and wellness.  Practice feeling your own Qi, aspects of health and longevity Qi Gong.

The fee for the class will be $80.00 per month.  There will be 3 sessions in this course.  The first session will be 2 months and the 2nd and 3rd session will be 3 months.  Everyone who is participating should wear exercise clothing and indoor running shoes.

After completing the course, you will receive a certificate.

Your first session is complementary.  If you are interested in attending any classes please call (705) 467-0701 or email  surso@ortho-sport.ca.

Our greatest assets are our health, physical, mental and emotional balance.  This program will fundamentally strengthen you on all levels – physical, energetically, and spiritual.

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Gift Certificates Available

 

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Is the Stress of Christmas getting to you and your loved ones, then give the gift of Health and Wellness this Christmas.  Orthopaedic Sport Institute has gift certificates for you, your friends and family.   You can use the gift certificates for massage therapy, chiropractor treatment, physiotherapy, personal training and nutritional counselling.  Help your loved ones keep their resolutions for the New Year by purchasing one of our gift certificates.  You can purchase them from our office administrators at 500 Ontario Street, Collingwood.

 

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Seminar for Hairstylists

Attention all Hairstylists!!!  

Benjamin Tkatch from http://www.salonblue.cais organizing an Ergonomics workshop in January hosted by Dr. Olivia Cheng  along with other practitioners from the Orthopaedic Sport Institute.

The two hour workshop will demonstrate the important relationship between posture, exercise and injury prevention. We will have some Nutrition tips as well. You all love what you do so let us help you keep making people happy and beautiful while taking care of your bodies in the process!!!

This Seminar will be held on Tuesday January 13, 2014 from 6:00pm – 8:00pm at Orthopaedic Sport Institute (www.ortho-sport.ca), 500 Ontario Street, Collingwood.  Seating is limited, please reserve a seat by emailing  surso@ortho-sport.ca, calling (705) 467-0701, or visiting our Facebook page and click on the event.

 

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Shockwave Therapy & Achilles Tendinopathy

There are now multiple medical trials that support the use of shockwave therapy (Extracorporeal Shock Wave Therapy – ESWT) for plantar fasciitis, tennis elbow (lateral epicondylitis) and calcific tendonitis of the shoulder.  Many people also suffer on a daily basis from a condition known as insertional achilles tendinopathy.  The following symptoms are now generally accepted and considered to be appropriate descriptors of this condition:

  • Insertional pain (i.e. pain at the heel where the Achilles tendon attaches) within 2 cm of the heel
  • Swelling
  • Loss of function

In the results of a recent study published in the American Journal of Sports Medicine, shockwave therapy is shown to be an effective treatment for chronic insertional Achilles tendinopathy.  Here are some key points from this study:

  1. At 1, 3 and 12 months after treatment, patients who received shockwave therapy demonstrated statistically greater results than the control group
  2. At 1, 3 and 12 months after treatment, patients who received ESWT without the use of local anaesthetic demonstrated greater improvements that patient who received ESWT combined with local anaesthetic

At the Orthopaedic Sport Institute, we offer shockwave therapy as an option to patients suffering from Achilles tendinopathy, shoulder tendonitis, plantar fasciitis and tennis elbow.  This treatment is offered in combination with standard forms of treatment for any of these conditions:

  • Manual therapy – with your physiotherapist, chiropractor and registered massage therapist
  • Custom Bracing/Orthoses
  • Anti-inflammatories (NSAID’s)
  • Active rehabilitation – stretching, strengthening
  • Platelet-Rich Plasma injections (PRP)
  • Consultation with an orthopaedic surgeon

If you are suffering from any of these impairments, please contact us at the Orthopaedic Sport Institute for a consultation with one of our registered healthcare professionals.  We will complete a detailed multi-disciplinary assessment to help determine the best course of treatment for your impairment.

Information for this article was taken from the study published in the AJSM: High-Energy Extracorporeal Shockwave Therapy as a Treatment for Insertional Achilles Tendinopathy. John Patrick Furia. Am. J. Sports Med. 2006; 34; 733

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Clippers Swim Team Seminar

Last night we welcomed the Clippers Swim Team to the Orthopaedic Sport Institute for a seminar on Shoulders.  Dr. Olivia Cheng Orthopaedic Surgeon spoke about the shoulder and how to prevent injuries before they happen.     Dr. Todd Starr, Chiropractor and Darryl Novotny, Physiotherapist were able to show the swimmers some exercises that would help keep them injury free.  Thank you to the Clippers and Dr. Cliff Noth for attending and being a great audience.  We look forward to the next Seminar in January with Dr. Yeates.

 

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Orthopaedic Sport Institute Seminar Series – Ski Ready

Ski ready seminar

Topics addressed included:

1. Patello-femoral syndrome, cause, prevention and treatment options.

2. MCL sprain, cause, prevention and treatment options.

3. ACL tears, cause, prevention and treatment options.

4. Back injuries and exercises for back injury prevention.

5. Dr. Starr gave individualized exercise demonstrations and instructions to our guests.

6. Dimitri Tkhinvaleli showed back exercise demonstrations to our guests.

7. Nick Kwasniak  shared his extensive knowledge on ski boot fitting and its importance in ski performances.

 

Thank you for all who participated, have a safe ski season

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Qi Gong – Ancient Core Energy Training

Qi Gong

FREE SEMINAR

Our greatest assets are our health, physical, mental and emotional balance.  This program will fundamentally strengthen you on all levels – physical, energetically, and spiritual.

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DATE: November 25, 2014

TIME: 6:30pm – 8:30pm

LOCATION: 500 Ontario Street, Collingwood, ON

Bringing up our abilities and performance to the highest possible level, properly conditioning our physical and energetic body.

AT THIS SEMINAR YOU WILL LEARN:

The importance of self-awareness and pre-requisites of true health.  Brief history of QiGong.  What is Qi Gong?  Clearing misconceptions, learning about life cultivation principle.  Anatomy and Physiology of Qi Gong.  Various types of Energy.  Various Qi Gong methods, medical, martial, philosophical.  Levels of Qi Gong learning.  Importance of regular training as a major requirement to steadily growing health and wellness.  Practice feeling your own Qi, aspects of health and longevity QiGong.

To Pre-register email:  info@ortho-sport.ca or call 705-467-0701

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Speaker:  Dimitri Tkhinvaleli, D.O.M.P, C.H., R.M.T., C.Z.S.P., Senior Instructor at Canadian Kuo Shu Martial Arts Federation and Chung Wah Kung Fu Martial Arts (Mississauga).

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