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Disclaimer 
• No
Take 
home 
-­‐ The 
magic 
number 
is 
5 
-­‐ In 
professional 
football: 
“With 
a 
good 
Rehab 
program, 
there 
is 
NO...
Catalan 
Match 
of 
the 
Magic 
5 
-­‐ Who? 
1 
* 
5 
years 
for 
FC 
Barcelona 
-­‐ When? 
3 
* 
5 
years 
a7er 
last 
La...
Use 
of 
Complex 
Growth 
Factor 
PreparaIons 
in 
the 
Management 
of 
Muscle 
Strain 
Injury 
ASPETAR 
Consensus: 
Febru...
Why 
Platelet 
Rich 
Plasma? 
• PRP 
– 2-­‐8 
Imes 
increased 
concentraIon 
platelets 
– Release 
of 
growth 
factors 
(G...
PRP 
in 
muscle 
injury 
Animal 
models: 
• Growth 
factors 
released 
by 
platelets(1-­‐3) 
– Myoblast 
proliferaIon 
↑ 
...
• Pilot 
study 
in 
grade 
2 
muscle 
injuries 
• PRP: 
N=18; 
• RetrospecIve 
controls 
Actovegin/Traumeel: 
N=11 
• Non-...
Evidence 
for 
PRP 
? 
• Conference 
abstract 
• 22 
muscle 
injuries 
“Magic 
Spanish 
5”: 
1. Full 
funcIonal 
recovery ...
Why 
Platelet 
Rich 
Plasma? 
Expected 
increase 
$45 
million 
(2009) 
to 
$126 
million 
in 
2016
Two 
recent 
RCTs 
Dutch 
study: 
• PRP 
not 
effecIve 
in 
acute 
hamstring 
injuries 
LimitaIons: 
1. Non-­‐professional...
Two 
recent 
RCTs 
Malaysian 
study: 
• PRP 
more 
effecIve 
than 
physio 
LimitaIon: 
1. Non-­‐blinded 
design 
Hamid 
MS...
Aim 
Establish 
the 
efficacy 
of 
PRP 
injecIons 
in 
acute 
hamstring 
injuries
Methods 
• Inclusion 
criteria 
ü Acute onset posterior thigh pain 
ü MRI confirmed Hamstring Injury gr I And II 
ü < 5...
Outcome 
measures 
• Time 
to 
return 
to 
play 
(RTP) 
StaIsIcal 
analysis: 
1. Cox 
regression 
(rate 
to 
RTP) 
2. Gene...
MRI 
variables 
• Size 
of 
edema 
– length 
(mm) 
– width 
(mm) 
– depth 
(mm) 
– cross-­‐secIonal 
area 
(cm2) 
– volume...
Study 
interven_on 
• InjecIon 
procedure 
– LocalizaIon 
on 
MRI 
and 
US 
– One 
procedure 
3 
injecIons 
PPP 
or 
PRP 
...
Standardized 
rehabilita_on 
program 
• Protocol 
created 
by 
Rehab 
staff 
(consensus) 
• 3 
experienced 
physio’s 
/ 
1...
Downloaded from bjsm.bmj.com on May 16, 2014 - Published by group.bmj.com 
Table 1 Criteria-based rehabilitation programme...
Sports 
specific 
func_onal 
field 
tes_ng 
Staged 
progression 
of 
volume 
and 
intensity 
of 
: 
• 
direcIon 
changes 
...
Return 
to 
sport 
decision 
• Blinded 
sports 
medicine 
physician 
• Clinical-­‐based 
decision 
• Successful 
and 
asym...
Results 
• Age 
25.8, 
SD 
5.7 
• 90% 
professional 
athletes 
/ 
83% 
Football/Futsal 
• PRP 
increase 
of 
platelets: 
f...
Results 
PRP: 
22.0 
(Unadjusted 
95%CI: 
17.8-­‐24.1) 
PPP: 
27.7 
(Unadjusted 
95%CI: 
20.6-­‐33.5) 
Physio: 
24.9 
(Una...
Adjusted 
Hazard 
Ra_o 
Adj 
HR: 
PRP 
vs. 
PPP 
= 
2.29 
(95% 
CI 
1.30 
to 
4.04) 
P=0.004 
Adj 
HR: 
Physio 
vs. 
PRP 
...
Adjusted 
results 
• Time 
to 
RTP: 
– PRP 
vs 
PPP: 
mean 
difference 
5 
days 
(adj 
95%CI 
-­‐10.1 
to 
-­‐ 
1.4) 
P=0....
UEFA 
study 
16% 
(2 
months) 
Re-­‐injury 
rate 
7% 
7% 
7% 
8% 
11% 
11% 
100% 
90% 
80% 
70% 
60% 
50% 
40% 
30% 
20% 
...
Decrease 
of 
edema 
on 
MRI 
(3 
planes)
Decrease 
of 
edema 
on 
MRI 
(volume)
Isokine_c 
strength 
at 
RTP 
Compared 
to 
contralateral 
leg
Conclusion 
• No 
benefit 
of 
PRP 
compared 
to 
Physio 
• Benefit 
of 
PRP 
compared 
to 
PPP 
ExplanaIon? 
Relevance? 
...
Discussion 
• Strength: 
– Professional 
athletes 
– Single 
center 
criteria-­‐based 
Rehab 
program 
– Placebo 
controll...
Take 
home 
-­‐ The 
magic 
number 
is 
5 
-­‐ In 
professional 
football: 
“With 
a 
good 
Rehab 
program, 
there 
is 
NO...
Thanks 
Key 
people 
• Dr 
Hakim 
Chalabi 
• Dr 
Mohammed 
Ghanem 
• Dr 
Khalifa 
Alkuwari 
Aspetar 
Consensus 
mee_ng: 
•...
Thanks 
Radiologist: 
• Dr 
Nabil 
Jomaah 
Lab 
technicians 
& 
Phlebotomists: 
• BharaI 
Shery 
• Sorainie 
Nunez 
• Mari...
Take 
home 
-­‐ The 
magic 
number 
is 
5 
-­‐ In 
professional 
football: 
“With 
a 
good 
Rehab 
program, 
there 
is 
NO...
Catalan 
Match 
of 
the 
Magic 
5 
-­‐ Who? 
1 
* 
5 
years 
for 
FC 
Barcelona 
-­‐ When? 
3 
* 
5 
years 
a7er 
last 
La...
Video 
Please 
start 
video 
and 
sound 
in 
Window 
player
Johannes Tol - hamstring injuries-  PRP
Johannes Tol - hamstring injuries-  PRP
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Johannes Tol - hamstring injuries- PRP

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Johannes Tol
Sports medicine physician, Aspetar, Orthopaedic and Sports Medicine Hospital, Doha, Qatar.
-
PRP for acute hamstring injuries: a 3-arm RCT in Qatar
(6th MuscleTech Network workshop)
14th October, Barcelona

Published in: Health & Medicine
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Johannes Tol - hamstring injuries- PRP

  1. 1. Disclaimer • No
  2. 2. Take home -­‐ The magic number is 5 -­‐ In professional football: “With a good Rehab program, there is NO need for PRP”
  3. 3. Catalan Match of the Magic 5 -­‐ Who? 1 * 5 years for FC Barcelona -­‐ When? 3 * 5 years a7er last La Liga championship -­‐ Why important? 5 * 5 matches without loss a7er his arrival -­‐ Where? 100 * 5 km South-­‐West from Barcelona -­‐ Which score? * 5 * 5 * 5 * 5 * 5
  4. 4. Use of Complex Growth Factor PreparaIons in the Management of Muscle Strain Injury ASPETAR Consensus: February 2009
  5. 5. Why Platelet Rich Plasma? • PRP – 2-­‐8 Imes increased concentraIon platelets – Release of growth factors (GF) – 2-­‐8 Imes increased GFs – PDGF (platelet derived GF) – TGF-­‐beta (transforming GF) – IGF-­‐I (insuline-­‐like GF) – PDEGF (platelet derived endothelial GF) – PDAF (platelet derived angiogeneis F) – PF-­‐4 (platelet factor)
  6. 6. PRP in muscle injury Animal models: • Growth factors released by platelets(1-­‐3) – Myoblast proliferaIon ↑ – Myofiber regeneraIon ↑ – Force ↑ Menetrey et al. 2000, Wright-­‐Carpenter et al. 2004, Hammond et al. 2009
  7. 7. • Pilot study in grade 2 muscle injuries • PRP: N=18; • RetrospecIve controls Actovegin/Traumeel: N=11 • Non-­‐randomised, Non-­‐blinded • Average 5 injecIons PRP!! • Return to play PRP: 17 days -­‐ almost normal MRI at 2 weeks!!! (?) Control: 22 days -­‐ abnormal MRI 5 days earlier RTP Wright-­‐Carpenter et al. IJSM 2004 Evidence for PRP ?
  8. 8. Evidence for PRP ? • Conference abstract • 22 muscle injuries “Magic Spanish 5”: 1. Full funcIonal recovery 2. 50% earlier than EXPECTED (?) RTP 3. Sonography: full regenerated muscle Issue 4. No fibrosis 5. No re-­‐injuries in any athlete, Sanchez et al. 2005 2nd InternaIonal Conference on regeneraIve medicine
  9. 9. Why Platelet Rich Plasma? Expected increase $45 million (2009) to $126 million in 2016
  10. 10. Two recent RCTs Dutch study: • PRP not effecIve in acute hamstring injuries LimitaIons: 1. Non-­‐professional athletes 2. MulIcenter Reurink G, Goudswaard GJ, Moen MH, Weir A, Verhaar JA, Bierma-­‐Zeinstra SM, Maas M, Tol JL; Dutch Hamstring Injec_on Therapy (HIT) Study Inves_gators. Platelet-­‐rich plasma injec_ons in acute muscle injury. N Engl J Med. 2014 Jun 26;370(26):2546-­‐7.
  11. 11. Two recent RCTs Malaysian study: • PRP more effecIve than physio LimitaIon: 1. Non-­‐blinded design Hamid MS, Mohamed Ali MR, Yusof A, George J, Lee LP. Am J Sports Med. 2014 Jul 29. 46-­‐7.
  12. 12. Aim Establish the efficacy of PRP injecIons in acute hamstring injuries
  13. 13. Methods • Inclusion criteria ü Acute onset posterior thigh pain ü MRI confirmed Hamstring Injury gr I And II ü < 5 days from injury ü Able to perform Physiotherapy at ASPETAR (5 / week) ü Available for follow-up ü Male ü Age > 18 years • 90 subjects randomized – PRP group (Biomet) – PPP group – Physio group (Regular care / no injecIon)
  14. 14. Outcome measures • Time to return to play (RTP) StaIsIcal analysis: 1. Cox regression (rate to RTP) 2. Generalized linear model (average RTP) Adjusted for baseline variables that influenced the primary outcome with p < 0.10 • Secondary § Re-­‐injury rate § MRI § IsokineIc strength
  15. 15. MRI variables • Size of edema – length (mm) – width (mm) – depth (mm) – cross-­‐secIonal area (cm2) – volume (cm3) • Extent of fibre disrupIon (mm) • Grading (0-­‐3) Hamilton B, Whiteley R, Almusa E, et al. Excellent reliability for MRI grading and prognos@c parameters in acute hamstring injuries. Br J Sp Med 2013 Nov 19. doi: 10.1136/bjsports-­‐2013-­‐092450. [Epub ahead of print]
  16. 16. Study interven_on • InjecIon procedure – LocalizaIon on MRI and US – One procedure 3 injecIons PPP or PRP • < 5 days a7er injury
  17. 17. Standardized rehabilita_on program • Protocol created by Rehab staff (consensus) • 3 experienced physio’s / 1 sports rehabilitator • Criteria-­‐based 6 stages, including field tesIng1 • PT: blinded to MRI (grading) and therapy • All 3 groups standardized Rehab Tol JL, Hamilton B, Eirale C, Muxart P, Jacobsen P, Whiteley R. . At return to play following hamstring injury the majority of professional football players have residual isokine_c deficits. Br J Sports Med. 2014 Feb 3
  18. 18. Downloaded from bjsm.bmj.com on May 16, 2014 - Published by group.bmj.com Table 1 Criteria-based rehabilitation programme for hamstring injury Stage Content Criteria to progress Stage 1 All activity to be pain-free 2 leg squat, or if able, single leg squat Maintain pelvis control, hip and knee alignment, squat to 45°, hold, return to start Supine Bridge—2 leg 2 s up, 2 s down (4 s total per rep.) Begin at 45°. Must reach knee-hip-shoulder in alignment. 4×15 supine isometric heel digs In supine, painlessly pull heel into bed through range. Can bias with tibial IR/ER when painless. Exercise bike Upright or recumbent, can substitute with elliptical trainer. Isometric manual-resisted hamstring Therapist applied resistance isometrically in varying angles in prone Soft tissue massage Proximal and distal to injury site, lymphatic drainage. Active range of motion exercises Supine active knee flexion and extension then Prone active flexion and extension Criteria to progress to stage 2: 1. Painless single leg squat 2. Painless bike, 150W 5 min 3. Full knee extension supine Stage 2 Any exercise from stage 1 permitted, additionally: Supine bridge—1 leg Same rate as for 2 legs, other knee in full extension, thighs parallel throughout exercise. 4×15 Walk-Jog Walk 20 m corners, jog the 30 m straight, painless. Begin at 25% (self-rated) jog, progress to max 70%. Triple extension walk 100 m laps, every third step triple extension—ie, alternating legs. ‘A’ drill Walking late swing knee extension, painless. Alternating legs, 100 m lap. Soft tissue massage Can massage injured area. Maximum allowed pain VAS: 4/10. Therapist uses caution with any report of discomfort, monitor symptoms, adjust accordingly Stretching Hamstring (supine, 90° hip flexion, knee extension); SLR (supine to onset of discomfort add ankle DF) Initially active, patient-controlled, progress to passive, end range. SLR mobilisation if indicated. Resisted hamstring Note tibial rotation as indicated. 4×15 repetitions, aiming for fatigue Original article Criteria to progress to stage 3: 1. Run !70% patient rated 2. ROM hamstrings !75% uninvolved side 3. ROM SLR !75% uninvolved side Stage 3 Any exercises from stages 1 and 2, additionally: Single leg bridge 1 s repetition, 2 s recovery. 4×8 repetitions. Single leg bridge, foot on Swiss ball 2 s up, 2 s down. 4×8 repetitions. Interval running 20 m jog 30 m run. Begin running at 70% (patient rated), progressing by 10% steps, painlessly. At 90%, progress by 5%. Monitor performance by hand timing. Modified T-Drill Direction changing running over T-Drill course. Begin at patient rated 70%, progress as able by 10% until 90%, then by 5%. Monitor performance by hand timing. Eccentric exercises Nordic Hamstrings, manual-resisted eccentric, prone catches, Arabesque (single leg stance, trunk flexion) Criteria to progress to stage 4 (sport-specific rehab): 1. 100% running speed 2. Painless high-speed direction changes Stage 4 Any exercises from stages 1–3, additionally on-field, football-specific drills: Direction change drills With and without the ball, 40 min Jumping drills 10–15 min Criteria to progress to stage 5 (sport-specific rehab): 1. Painless completion of stage 4 Stage 5 Passes and run Long passes progression Crosses (static) Corner kicks Crosses (dynamic) Criteria to progress to stage 6 (sport-specific rehab): 1. Painless completion of stage 5 Stage 6 Passes and run Shooting scenarios Competitive 1 versus 1 drills Shooting scenarios Scoring scenarios Criteria to progress to medical review for return to sport: 1. Painless completion of stage 6 DF, dorsiflexion; ER, external rotation; IR, internal rotation; Modified T-Drill, (always) forward running over the course of the Agility t test; ROM, range of motion; SLR, straight leg raise.
  19. 19. Sports specific func_onal field tes_ng Staged progression of volume and intensity of : • direcIon changes • sprints • jumps • (cross-­‐) passes • shooIng • interval running • one -­‐ on -­‐ one aracking • defence drills mimicking muscle faIgue and compeIIveness during football training and game situaIons
  20. 20. Return to sport decision • Blinded sports medicine physician • Clinical-­‐based decision • Successful and asymptomaIc compleIon of the progressive criteria-­‐based rehabilitaIon programme, including the sports specific funcIonal field tesIng • ReflecIon of daily pracIce
  21. 21. Results • Age 25.8, SD 5.7 • 90% professional athletes / 83% Football/Futsal • PRP increase of platelets: factor 3.2 • Baseline variables associated with RTP were (P<0.10): – Pain score at injury (0-­‐10) – Volume of edema on MRI (cm3)
  22. 22. Results PRP: 22.0 (Unadjusted 95%CI: 17.8-­‐24.1) PPP: 27.7 (Unadjusted 95%CI: 20.6-­‐33.5) Physio: 24.9 (Unadjusted 95%CI: 21.5-­‐28.5) PRP PPP Physio
  23. 23. Adjusted Hazard Ra_o Adj HR: PRP vs. PPP = 2.29 (95% CI 1.30 to 4.04) P=0.004 Adj HR: Physio vs. PRP = 0 .67 (95% CI 0.39 to -­‐1.16) P=0.15 Adj HR: Physio vs PPP = 1.57 (95% CI 0.88 to -­‐ 2.80) P=0.13 -­‐ Weeks
  24. 24. Adjusted results • Time to RTP: – PRP vs PPP: mean difference 5 days (adj 95%CI -­‐10.1 to -­‐ 1.4) P=0.01 – No difference between: – PRP vs Physio – Physio vs PPP PRP PPP PHYS
  25. 25. UEFA study 16% (2 months) Re-­‐injury rate 7% 7% 7% 8% 11% 11% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% PRP PPP Physio Re-­‐injury-­‐ ≤2m Re-­‐injury-­‐ <6m
  26. 26. Decrease of edema on MRI (3 planes)
  27. 27. Decrease of edema on MRI (volume)
  28. 28. Isokine_c strength at RTP Compared to contralateral leg
  29. 29. Conclusion • No benefit of PRP compared to Physio • Benefit of PRP compared to PPP ExplanaIon? Relevance? • No difference re-­‐injuries, MRI, strength
  30. 30. Discussion • Strength: – Professional athletes – Single center criteria-­‐based Rehab program – Placebo controlled double blind design (PRP,PPP) • LimitaIons – Third arm (physio group) not blinded (bias?) – Specific elite athlete seung (generalizability?) – GF content PRP and PPP (pending)
  31. 31. Take home -­‐ The magic number is 5 -­‐ In professional football: “With a good Rehab program, there is NO need for PRP”
  32. 32. Thanks Key people • Dr Hakim Chalabi • Dr Mohammed Ghanem • Dr Khalifa Alkuwari Aspetar Consensus mee_ng: • Dr JusIn Grantham • Patrick Schamasch IOC • Alain Garnier WADA • Bengt SalIn • Xavier Bigard • Burhan Gharaibeh • Antonio Gigante • Ramon Cugat • Donald Kuah • Franco Benazzo • Francois Kelberine • Brent Kirkbride • Tarek El Nidani • Riadh Miladi Aspetar • Peter Fowler Aspetar • Dean Kenneally Aspetar SMP: • Dr JusIn Paoloni • Dr Bruce Hamilton • Dr Claude Tremblay • Dr Massimiliano Sala • Dr Eduardo Mauri • Dr Celeste Geertsema • Dr Robbart van Linschoten • Dr Johannes Tol • Dr Aston Ngai • Dr Andrew Miller • Dr Stephen Targer • Dr Adam Weir • Dr Frank van Hellmondt • Dr Liesel Geertsema • Dr Massimo Manara • Dr Paul DIJKSTRA Fellows: • Dr Bhavesh Kumar • Dr Mar Robinson • Dr Floor Groot • Dr Robert Johannes de Vos • Dr Elke van den Steen Research Nurse: • Sirine Boukarroum Physiotherapist: • Rod Whiteley • Philipp Jacobsen • Patrice Muxart • Roald Oren • Mohsen Abassi Research assistance/ Researcher: • Faten Smiley • Arnlaug Wangensteen • Andreas Serner • Dr Vidya Mohammad Ali • Wade Knez • Rima Tabanji Other nurses : • Pascale Tahtouh • Nelly Khalil Orthopaedic surgeons: • Dr Phillipe Landreau • Dr Nebojsa Popovic • Dr Mareo Regusci • Dr Pieter D’Hooghe
  33. 33. Thanks Radiologist: • Dr Nabil Jomaah Lab technicians & Phlebotomists: • BharaI Shery • Sorainie Nunez • Maria Galabo • Khalidah Mansour • Maya Kemaldean Gharziddine • Dr Emad Almusa • Dr Bernard Roger Radiographers : • Andrew Roshan • Brendan Mundey • Donna Smith • Eihab AbouHashem • LaIfa Saifeldin • Mohamed Nawas • Mahmooda Banu • Toni Evans • Tessa Smith Other Radiology Staff: • Salwa Allenjawi • Natalia Hatamova • Rachid Aiaou Clubs and Federa_ons: • Al Ahli Sports Club • Al Arabi Sports club • Al Gharafa Sports Club • Al jaish team • Al khariIyath Sports Club • Al Khor Sports Club • Al Markhiya Sports Club • Al Rayyan Sports Club • Al Sadd Sports Club • Al Sailiya Sports Club • Al Shahaniya Sports Club • Al Shamal Sports Club • Al Wakrah Sports Club • Mesaimeer Sports Club • Military Sports AssociaIon • Moaither Sports Club • Olympic commiree • InternaIonal Athlete • Lakhwaya Sports Club • QATAR HOCKEY FederaIon • Qatar Sports Club • Qatar Armed Forces • Qatar Basketball FederaIon • Qatar Football AssociaIon • Qatar Taekwondo & Karate FederaIon • Qatar Weightli7ing & body building FederaIon • Qatar NaIonal team • Um Salal Sports Club
  34. 34. Take home -­‐ The magic number is 5 -­‐ In professional football: “With a good Rehab program, there is NO need for PRP”
  35. 35. Catalan Match of the Magic 5 -­‐ Who? 1 * 5 years for FC Barcelona -­‐ When? 3 * 5 years a7er last La Liga championship -­‐ Why important? 5 * 5 matches without loss a7er his arrival -­‐ Where? 100 * 5 km South-­‐West from Barcelona -­‐ Which score? * 5 * 5 * 5 * 5 * 5
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