Batting clean-up
Dr. Blecher offers his final (promise) thoughts:
"As previously stated, I agree that the PRP studies are less than perfect. Despite Dr. Mall's critiques, however, they do show statistically significant improvements with PRP therapy. We could discuss the merits of each study ad infinitum because perfect studies on new treatments rarely occur. But it should be noted that such flawless studies do not exist for many of the alternative treatments that Dr Mall suggests including the benefit of:
- Rest
- Decreasing/Stopping irritating activity
- Stretching
- Eccentric strengthening
- Ultrasound
- Heat/Cold
- Electrical Stimulation
- Cross Friction Massage
- Astym (soft tissue therapy)
- Bracing
- Compression Wrap
- Medication (anti-inflammatories)
- Steroid Injections
- Acupuncture
- Cold Laser; and
- Diet (Omega 3s)
In fact, treatments such as physical therapy, steroid injections and even surgery often lack this type of evidence to substantiate their use for many of the indications for which they and PRP are used. I think it is safe to say that we agree that PRP treatment is not a panacea for all musculoskeletal conditions and should be used only in appropriate situations. It is up to each practitioner to synthesize the available evidence and determine how it will affect his or her practice.
I, for one, do find a growing role for PRP in my sports medicine practice. Dr Mall states that he has used it as well, which suggests that he must believe in its potential benefit to some degree. He is not alone. There are a growing number of well-informed patients who have tried and failed other treatments and seek out PRP therapy as an option of last resort. This includes patients who have failed surgery as well.
As with any procedure (surgery and PRP included), it is important that the patient have informed consent as to the potential risks and benefits of the treatment as well as the other treatment options available to them. If a practitioner does not believe enough in the potential benefits of a treatment until it is proven "beyond a reasonable doubt", then they will simply not offer that treatment.
But we should be aware that many of the alternative treatments listed above have not reached that same threshold of proof either and therefore to suggest one over another is somewhat arbitrary, and may just reflect the practitioners relative lack of experience with that particular treatment or may be based solely on cost. Treatments such as corticosteroid injection have never been shown to provide long term benefit and, in fact, have been shown to be detrimental to cartilage, tendon and ligament cells, yet they are commonly used because they are cheap, easy and provide quick pain relief.
These "standard treatments covered by medical insurance" continue to fail for many patients. If we as practitioners continue to stick with cheap and easy until something that is more expensive is proven beyond a reasonable doubt, then we are just as bad as the insurance companies who continue to deny coverage on certain procedures until they have become the standard of practice.
I believe that PRP will one day have the preponderance of evidence in its favor when used appropriately, and insurance companies will realize that it is cheaper than surgery and requires little to no down time or missed work. In fact, there are now some worker's compensation insurance carriers that have started covering PRP treatments, as they too become convinced of its cost-effectiveness.
Injuries to professional athletes are covered by worker's compensation insurers and, as evidenced in the media, there are a growing number of athletes undergoing these procedures. Although all of my athletic patients are not professional or elite athletes, I certainly try to treat them as such. If treatments such as PRP have been shown to provide benefits in certain situations, then I will continue to offer these treatments to all of my well-educated patients, even though cost may be a barrier to some.
Ultimately we as doctors are educators. We educate our patients as to our beliefs as to what treatments would benefit them. The educated patient choses to agree or disagree with our recommendations. Hopefully articles such as this provide patients with more information to make those choices."
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Posted October 10, 2013; updated October 18, 2013 to include Dr. Blecher's final comments
