Sep 22, 2016Looking to Score
Shawn Felton, EdD, LAT, ATC, is Assistant Professor of Rehabilitation Sciences at Florida Gulf Coast University. Prior to his appointment at FGCU, he was the Athletic Training Coordinator for Naples (Fla.) Community Hospital, where he supervised a staff of nine athletic trainers who provided coverage to Collier County Public Schools. He can be reached at: [email protected].
Michael Estes, MS, LAT, ATC, is Senior Associate Athletics Director for Administration at Florida Gulf Coast University, having previously served as the school’s Head Athletic Trainer, Assistant Athletics Director, and Associate Athletics Director for Health Performance. He can be reached at: [email protected]
Depending on which athletic trainer you ask, they might say that platelet-rich plasma (PRP) therapy is a game-changer — or they might say its effectiveness is questionable. Because the platelet concentrations used in PRP therapy vary, the research on its use is inconclusive, and there are no established guidelines related to its application. Yet, anecdotal evidence suggests that PRP treatments aid in the recovery of soft-tissue injuries.
Some of that evidence has come out of Florida Gulf Coast University. We started offering PRP to FGCU athletes at our local team physician’s office in 2010. It was meant as a final treatment option for chronic tendon, muscle, and bone injuries that weren’t responding to conservative modalities. With PRP, we saw the majority of our student-athletes’ chronic conditions resolve, and they were able to return to a high level of practice and play without the use of NSAIDs.
These results inspired us to bring PRP to the FGCU sports medicine facility in 2013 — believed to be one of the first schools to offer PRP on campus for its student-athletes. In the three years since, we’ve continued to see positive outcomes with this modality, and we’re striving to produce empirical, quantifiable data to support its ongoing use in the treatment of chronic pathologies. By providing an overview of PRP therapy and explaining our protocols, we hope you will learn from our experiences thus far — regardless of your current opinion on PRP’s efficacy in the athletic setting.
COVERING THE BASICS
The goal of PRP therapy is to stimulate the healing through the injection of a local irritating substance into an injured area. The substance is comprised of blood drawn from the athlete who will be receiving the treatment. Using the patient’s own blood reduces the chances of rejection, infection, or system reaction.
Prior to injection, the blood is processed through a centrifuge, resulting in a dense plasma suspension that consists of three to eight times the concentration of platelets as whole blood. The increased number of platelets is significant because of the role they play in the healing process. When the initial inflammatory response occurs after tissue injury, a fibrin clot forms. Within the fibrin clot, platelets accumulate to begin repairing tissue.
Therefore, the highly concentrated presence of platelets in a PRP injection greatly increases the number available to initiate healing. By delivering them directly to the injury site, PRP therapy can, in theory, incite and augment inflammation, thus enhancing tissue repair.
A higher concentration of platelets also decreases the time required for circulation-derived cells, such as macrophages and fibroblasts, to reach the site of injury and continue the healing process. It has been reported that macrophages proliferate at higher rates following a PRP treatment. This is beneficial because active macrophages help reduce fibrosis and scarring and improve healing in chronic wounds.
PRP therapy can be applied in two ways — either directly injected at the site of injury or administered intraoperatively. The latter procedure can be completed at the end of an arthroscopic or open surgery by applying the concentrated PRP substance over the repaired tissues. We use both methods with the student-athletes at FGCU.
ON-SITE OFFERING
The impetus for bringing PRP to FGCU’s campus in 2013 was a conversation with our Head Team Physician, James Guerra, MD. Since a number of our athletes had success after receiving PRP as a last-ditch treatment option at a doctor’s office, we asked Dr. Guerra about getting it at FGCU so we could use it earlier in the recovery process.
He explained that we would face two major stumbling blocks in this endeavor: 1) The cost of purchasing PRP equipment and injection kits, and 2) Insurance companies’ unwillingness to cover the procedure because of the uncertainty surrounding its efficacy. With minimal insurance coverage, the cost of the procedure would fall to our student-athletes. They are required to carry their own primary insurance, and we provide secondary coverage. Unfortunately, any costs for PRP not covered by their primary insurance would then be charged to our secondary insurance, thus risking increased premiums. If we were going to offer PRP to more student-athletes, we needed to make sure it would be affordable for both them and our athletic department.
After several more conversations with Dr. Guerra, we decided to set up a PRP “clinic” in our main athletic training facility’s physician suite. Arthrex Corporation, a global medical device company based in nearby Naples, Fla., agreed to donate the PRP equipment we needed, such as a centrifuge and diagnostic ultrasound. We purchased the injection kits from Arthrex through our sports medicine budget.
Although the physician’s suite is limited in size, offering PRP on campus is a much better setup than before. For starters, insurance has been completely removed from the equation. Since the treatment isn’t performed in a doctor’s office anymore, there is no physician billing component, and no costs are passed on to our student-athletes. There are minimal athletic department expenses, as well, because of the donated PRP equipment.
Second, we’re able to offer early intervention. If the attending team physician believes PRP is an appropriate therapy method for an injured athlete, it can be carried out right then and there. We don’t have to check to see if it will be covered by their insurance first. Plus, we no longer have to wait until the next office day for our team physician to perform PRP therapy, giving us a jump on rest and recovery.
OUR PROTOCOL
The decision to use PRP as a treatment option for a FGCU student-athlete is determined by Dr. Guerra in consultation with the treating athletic trainers. Prior to application, patient education is paramount. Many athletes are familiar with PRP based on what they hear from the media, but we start by ensuring they have a clear understanding of the procedure. Athletes will often need more than one PRP injection to heal their chronic injury, and we explain this in the beginning so they don’t expect one treatment to solve their issue.
A tough area of compliance following PRP injection is keeping athletes from taking any type of NSAID — normally a standard for pain relief following soft-tissue injury. This requires some extra education up front. We tell athletes that we want an inflammatory response with a PRP injection because inflammation is the way they’ll heal. Since NSAIDs limit or stop the inflammatory response, they render PRP ineffective.
When completing the procedure, all blood draws, PRP preparation, and injections are performed by the team physician under sterile conditions. Athletic trainers assist with the student-athlete and specimen preparation. To maximize the effectiveness of the treatment, the injections must be precise. We use guided musculoskeletal ultrasound to ensure the PRP is delivered to the affected site.
The final phase of the PRP protocol is the post-injection treatment plan, which includes monitoring by an FGCU athletic trainer, follow-up by Dr. Guerra, and a prescribed rehabilitation plan. Post-injection rehab is probably the trickiest aspect of PRP therapy because there’s a lot of uncertainty around it. When we started using PRP at FGCU, we didn’t know if athletes should rest following injections, whether we should use conventional modalities like ice and heat during rehab, or when, how, and at what frequency to initiate rehabilitation exercise. Unfortunately, the literature wasn’t much help, as various protocols produced a myriad of results.
So, through trial and error and utilizing the most comprehensive research we could find, we came up with our own rehabilitation plan. We begin with what we call the “rest/recovery phase,” which means no athletic activity for seven to 10 days immediately following a PRP procedure. Then, we incorporate rehabilitation exercises consisting of a combination of neural glides and eccentric work. We perform heat therapy before rehab, with e-stim, compression recovery, and cold therapy afterward, as needed. Gradually, we return athletes to activity as tolerated. (See “Case Study” below for an example of an athlete who has gone through our PRP treatment and rehab protocol.)
After the first injection, the team physician and athletic trainer determine if more are needed. This decision is based on a number of factors, such as extent of original tissue damage, symptoms, time of year, level of resolution, etc. Anywhere between six and eight weeks can pass between injections — there is no standard time frame.
If an athlete does need more than one PRP injection, any subsequent rehab is based on their symptoms. They might need complete rest for a period of time after the second dose, or they might continue with the rehab plan from their first injection. Every student-athlete is different.
FUTURE DIRECTIONS
In the past three years, we have done 50 PRP injections — 32 initial injections and 18 secondary ones. Every FGCU athlete who has tried PRP has seen resolution except one, which was likely because that individual chose not to continue treatment with a second injection.
For schools that are thinking of offering PRP on their own campuses, we advise getting physician support and staff buy-in first. Then, be sure you have a dedicated space and ample funding sources.
Also, athletic trainers should be prepared for longer clinical hours, as they must be present for all PRP injections. However, keep in mind that on-campus PRP saves athletic trainers from having to take athletes to an off-campus physician’s office, where the procedure can take more than twice as long depending on how many other patients are waiting to be seen.
Since we started using PRP on FGCU athletes, the treatment method has been a tremendous aid in the recovery of chronic soft-tissue injuries, and we’ve met our goal of collecting evidence to support what we do. Yet, we advise other athletic trainers to continue to use caution with PRP administration. Although it appears to provide an adjunct to sports medicine professionals anecdotally, best practices need to be determined to quantify results and overall efficacy before widespread acceptance can occur.
To view a list of references for this article, go to: Training-Conditioning.com/References.
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CASE STUDY
One of our earliest successes administering platelet-rich plasma (PRP) therapy at Florida Gulf Coast University came with a baseball pitcher suffering from chronic patella tendonitis. He had been receiving conservative treatment throughout the fall semester with limited success.
While hiking during winter break, he felt a “pop” in his knee. Once he returned for the spring semester, a MRI revealed that the injury was a moderate grade partial intra-substance tear of the patella tendon at its origin.
Instead of trying conservative treatments for both the tendonitis and tear, we went right to PRP injection. After a local anesthetic was administered, the PRP concentration was inserted to the area within and around the intra-substance tear utilizing guided ultrasound. We employed a “peppering” technique, which consists of five penetrations at the site of injury. Peppering was used due to the chronic nature of the tendonitis prior to the tear. It allowed for the PRP to affect a greater area beyond the site of the tear, facilitating healing in tissue that lacked a sufficient blood supply for normal healing.
Following the injection, FGCU’s Head Team Physician, James Guerra, MD, instructed the athlete to refrain from sport participation for seven days. However, he began non-aggressive rehabilitation immediately.
The aim with his rehab was to help, but not aggravate, the injury site. Prior to any exercise, the athlete received thermal therapy consisting of a hydrocollator pack and three megahertz of continuous ultrasound at 1.2 W/cm2 for 10 minutes. This served to “warm-up” the injured tissue. Then, his rehab consisted of straight-leg raises, one-quarter wall squats, quad setting exercises, stretching exercises, and low-intensity stationary bike workouts. After completing the exercises, he received interferential electric stimulation and cryotherapy, which served as a “cool down.”
Ten days following the injection, the athlete resumed modified activity, consisting of light throwing on flat ground. Fifteen days post-injection, the athlete had shown further improvements, so he advanced to throwing from the mound. He continued the progressive rehabilitation for an additional 10 days until he achieved full strength, at which point he was released to full activity. The athlete made a complete recovery and no longer experienced pain or swelling in his knee.
This article first appeared in the October 2016 issue of Training & Conditioning.
