Gumption

PRP, Regenokine & other biologic medicine treatments for joint & tendon problems

Science journalist Jonah Lehrer posted an interesting article last week about aging star athletes' embrace of biologic medicine, "Why Did Kobe Go to Germany? An aging star and the new procedure that could revolutionize sports medicine". The article describes Regenokine, a relatively new procedure for treating joint and tendon problems that sounds similar to the platelet rich plasma (PRP) treatment I underwent for my right elbow nearly 5 years ago. I have enjoyed a nearly full recovery from the pain and limitations of chronic elbow tendinosis that had plagued me on and off for several years prior to treatment, and I enjoyed reading about others' successful treatment experiences and some of the studies about treatment alternatives.

"Biologic medicine" treatments all engage the body in healing itself, typically involving the extraction, manipulation and re-injection of the patient's own blood or other bodily fluid. Regenokine treatment involves withdrawing a small sample of blood from the patient, heating it and then spinning it in a centrifuge to separate the constituent elements; the resulting yellow colored middle layer is then extracted and injected into the patient's problem area (e.g., the knee). PRP involves withdrawing blood and spinning it in a centrifuge, but does not involve heating, and - as the name suggests - the platelet-rich layer is extracted for injection. Bone marrow injections, involving stem cells, use a similar approach.

Unfortunately, the article reports that PRP, Regenokine and other "biologic medicine" treatments face special challenges in securing FDA approval:

The reason Kobe, A-Rod, and other athletes travel to Germany for their biologic treatments involves a vague FDA regulation that mandates that all human tissues (such as blood and bone marrow) can only be "minimally manipulated," or else they are classified as a drug and subject to much stricter governmental regulations. The problem, of course, is figuring out what "minimal" means in the context of biologics. Can the blood be heated to a higher temperature, as with Regenokine? Spun in a centrifuge? Can certain proteins be filtered out? Nobody knows the answer to these questions, and most American doctors are unwilling to risk the ire of regulators.

The article profiles athletes Kobe Bryant and Alex Rodriguez, as well as Regenokine treatment providers Dr. Peter Wehling (Dusseldorf, Germany) and Dr. Chris Renna (Lifespan Medicine, Dallas & Santa Monica) - who are also co-authors of the book End of Pain - and PRP treatment providers Dr. Stephen Sampson (Orthohealing Center & UCLA) and Dr. Allan Mishra (Apex PRP & Stanford), the doctor who treated my elbow.

Lehrer offers a balanced perspective, noting that while a few famous athletes appear to have experienced healing after biologic medicine treatments, there is - as yet - little supporting evidence from rigorous clinical trials, and so these could represent "the latest overhyped medical treatments for desperate athletes". A 2006 article co-authored by Mishra described a pilot study showing the effectiveness of PRP for chronic elbow tendinosis (the problem I was suffering from), and a 2010 article co-authored by Sampson described another pilot study showing the effectiveness of PRP on knee osteoarthritis. However a 2010 article reported on a Dutch study that showed no significant benefit of PRP over saline injections for chronic Achilles tendonopathy. Another Dutch study, involving a double-blind randomized trial of PRP with 230 patients has been completed, but it could be another several years before the results appear in a peer-reviewed medical journal. Mishra's blog includes a recent post referencing other studies supporting the effectiveness of PRP.

I don't know of any studies of Regenokine, but a 2008 pilot study of interleukin-1 receptor antagonist did not demonstrate significant benefit to treating knee osteoarthritis demonstrated "statistically significant improvement of KOOS [Knee injury and Osteoarthritis Outcome Score] symptom and sport parameters", and a 2009 study reports that Autologous conditioned serum (Orthokine) is an effective treatment for knee osteoarthritis. According to a December 2011 post about PRP and Regenokine in the Wordpress blog, Knee Surgery Newsletter (which offers no information about the author), Orthokine was the brand name under which Regenokine was previously marketed, and Regenokine and Orthokine are both brand names for interleukin receptor antagonist treatment.

The Lehrer article also highlights doubts - or what should be doubts - about the effectiveness of the traditional alternative to biologic medicine treatment - surgery - describing the results of a 2002 peer-reviewed study appearing in the New England Journal of Medicine, A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee:

Consider an influential 2002 trial that compared arthroscopic surgery for knee osteoarthritis to a sham surgery, in which people were randomly assigned to have their knee cut open but without any additional treatment. (The surgeon who performed all the operations was the orthopedic specialist for an NBA team.) The data was clear: there was no measurable difference between those who received the real surgery and those who received the fake one.

As I've noted before in the PRP thread here on my blog, I'm not a medical expert, and I don't even follow the medical literature about PRP or other treatments with any regularity (I discovered this article because I follow @jonahlehrer on Twitter). I have enjoyed a complete recovery of functionality and nearly pain-free use of my elbow following PRP therapy. I like to think that there is a causal relationship in my personal experience - especially after the failure of several other treatments I tried - but as noted in Lehrer's article, more evidence is required to support any general conclusions on the effectiveness of the treatment. Meanwhile, I'm happy that to see PRP and other biologic treatments gain greater recognition and awareness.

16 month update on my elbow Platelet Rich Plasma (PRP) treatment

In November, I visited Dr. Allan Mishra's office for a belated followup on the platelet rich plasma (PRP) treatment for elbow tendonitis he'd administered in July 2007. As was the case before my six month followup visit, I was feeling a bit disheartened at the condition of my right elbow. And fortunately, as was the case after that visit, I was once again heartened (reheartened?) at both my current condition and future prospects.

Despite over 16 months having elapsed since the PRP injection, I was still feeling pain after any kind of even moderate exertion, e.g., giving my wife a neck massage while sitting together on the couch. Although the pain was relatively minor, it was still recurring regularly (I like to give Amy neck massages), at a time when I had hoped that everything would finally be back to normal.

I was supposed to return to the Menlo Sports Medicine clinic for a 12-month followup visit, but due to a job change, I hadn't been in the Bay area since last January. Amy had mentioned the ongoing lack of full resolution to a local orthopedic surgeon who was treating my son's broken knee in July, who suggested we may want to consider surgery. Around that time, I had a paper accepted to the CSCW 2008 conference in San Diego (held in November), so I decided I'd stop off in San Francisco on my return to visit Dr. Mishra and see what he had to say.

After describing the persisting symptoms to Dr. Mishra, he examined my elbow, performed a few tests, and asked me where exactly the pain was located. The tests revealed that my grip strength was holding steady at 135 psi, with a pain level of [at most] 1 out of 10 (compared with a pre-injection grip strength of 65 with pain level 5), my wrist extension was a full 5 out of 5 with a pain level less than 1 (vs. pre-injection levels of 4 / 5 and a pain level of 9), and palpation - level of tenderness in my elbow - had decreased from 8 or 9 down to 1. I pointed to the the outer part of my forearm, about an inch or two below the elbow, as the area with the pain. When he asked whether there was any pain in the elbow itself, I realized that there was none (doh!).

Dr. Mishra told me that however long a joint has been in a state of injury or disrepair, it typically takes twice as long - after [successful] treatment - for it, and the surrounding area, to fully heal. This is, in part, due to atrophy in the affiliated muscles that occurs after long periods of reduced use or disuse. Given that my elbow was in a compromised state for a large portion of the nearly 3 years prior to the injection, it could take 5-6 years for the elbow - and the upper forearm - to fully return to normal :-(

Despite this rather sobering news, he told me he considered me a "poster child" for PRP treatments for the elbow. My elbow had been in the worst shape of any person he's yet treated solely with PRP; typically, he would have combined the PRP injection with surgery for someone who had suffered so long. The progress I've made thus far has been very encouraging to him, which offers further encouragement to me, and he thinks that it likely that I - or, at least, my elbow - will eventually return to normal.

We then talked about the theraband exercises he'd prescribed, I admitted I'd not been very diligent in doing them (probably around once every several weeks, rather than several times per week). I also told him that the exercises often triggered elbow pain (and pain in the upper forearm), and so he asked me to show him how I was performing them. He noted that I was going overboard in the exercises - bending at the elbow rather than the wrist, and thus placing unnecessary (and counteproductive) stress on the elbow joint. He said this was a common misapplication of the exercises, and after showing me how to do them correctly - bending slowly at the wrist - I suggested that maybe I could create and post a video of the right (and wrong) ways.

So, after some delay, I've created and posted my first public YouTube video, Elbow Exercises, post-PRP treatment:

As I note in the video narration, I'm hoping that this public posting of the video will both help others perform the exercises correctly, and provide additional motivation for me to perform them more regularly. And hopefully, sometime in the next few years, I'll be able to post yet another update, reporting that my elbow has completely healed.

Six month update on my elbow Platelet Rich Plasma (PRP) treatment

Amid the broad range of emotions and activities in which I'm engaging this week - a sad last week at Nokia before an exciting new start at MyStrands - I was able to schedule an appointment for my 6-month followup visit with Dr. Mishra regarding progress on the platelet-rich plasma (PRP) treatment for my right elbow. [I am very grateful for Kevin's recent comment on an earlier PRP-related post, and an email from Mark, who had commented on my first elbow PRP post - and who has since also undergone the PRP treatment - which reminded me that I needed to schedule this appointment before I leave town.]

I was not looking forward to the visit, in part because I have not been diligent in my theratube exercises (probably averaging once every three days rather than three times per day since my three-month PRP checkup), and in part because I thought that if I wasn't 100% back to normal by now, I would have to choose between surgery and living with my elbow's current status, which is probably around 90% of pre-tendonitis strength (and absence of pain).

However, my fears, as is so often the case, were unfounded - at least with respect to the latter one (I should [still] resume more diligent theraband exercising). I found out that it can take up to 12 months for the full effects of PRP to manifest themselves, so the fact I'm not completely "cured" is not surprising, and in fact, my current status, in which I rarely feel pain greater than 3 (on a scale of 10) - even after moving a humongous solid oak entertainment center from our bonus room to the garage last weekend - is a significant improvement over the last checkup.

During this visit, I was able to exert 135 pounds of grip strength with my right hand with a subjective pain level of 1 (vs. 120 pounds of grip strength with a pain level of 4 at the 3-month mark), and was able to resist attempts to pull down my upturned or downturned hand with a pain level of 1 or 0. As I noted earlier, during my first visit, I was only able to exert 65 pounds before I hit the wall (of pain) at level 9, and my resistance was lower and pain higher for the upturned hand exercise. It is relatively rare for my elbow to be sore - except after I move heavy furniture or engage in repetitive motions for extended periods.

Among the differences I've noticed in the past 3 months were:

• being able to carry around and drink from my 20-oz coffee mug with no pain
• being able to carry heavy furniture with some pain (I would not have even attempted to move the entertainment center 3 months ago)
• being able to do pushups with little pain (again, I would not have attempted pushups 3 months ago)

Dr. Mishra was actually quite encouraged - and encouraging - about my prospects for eventually regaining full use of the elbow with little or no pain! And, even better (to me), he suggested that if I have not reached that status by the 12-month mark, given the progress I've shown thus far, he would now recommend a second PRP treatment rather than PRP + surgery (which is what I thought would be the next step).

So, once again, my optimism is restored. I just did a round of theratube exercises (that makes 3x today), and will gradually start experimenting with exercising more regularly - pushups and perhaps even full-scale elliptical training (now that I'll be home - where we have a Precor FX - more regularly) - though ramping up on an [uncharacteristically] gradual slope. I will also restart my yoga practice.

I noted in my response to Kevin's comment that Dr. Mishra's PRP web page had a link to the Total Tendon Network, and that while I was excited about encountering my first Ning network "in the wild", it appeared to be a site targeting [only] tendon care providers:

This is a group of providers dedicated to improving the diagnosis, treatment and prevention of tendon related disorders.

Dr. Mishra told me that the site was, in fact, intended for both providers of treatment and patients who are receiving, or considering receiving, treatment (he said he will change the text on the login page - and said he requires login to ensure some level of quality control on this social network). I've signed up, but am still waiting for "approval", and so will report further on the Total Tendon Network during my next update ... probably around six months from now.

Three month update on my elbow Platelet Rich Plasma (PRP) treatment

On Monday, I had a followup visit with Dr. Mishra to evaluate and discuss progress and prospects for the restored health of my right elbow, three months after my treatment with Platelet Rich Plasma (PRP). One week after treatment, things had gotten worse (though, as Dr. Mishra had warned, this is often the case shortly after treatment). At the one-month mark, my elbow was feeling pretty much like it had just before the treatment. At this point, I'm happy to report that my elbow feels better than it did before the treatment, though still not as well as it felt before the initial injury.

Among the daily activities that I have resumed doing with reduced pain are

• drinking my 22-ounce mug of coffee with my right hand
• doing full-form yoga sun salutations (including the elbow-loading cobra pose and downward-facing dog pose, which I'd been omitting from my routine until recently)
• flossing my teeth with regular dental floss (vs. floss picks)
• scrubbing pots & pans

On Sunday, I was moving our four 20-pound Lafuma recliner chairs from the deck to the garage (one at a time), requiring a relatively significant amount of elbow strength and agility (given the rather cramped state of our garage). Although my elbow was sore afterward for a few days, I was surprised I was able to pick the chairs up at all - and, as with some of the activities I mentioned in my last update, I probably should not have pushed (or pulled) that hard.

During the visit on Monday, I was able to exert 120 pounds of grip strength with my right hand with a subjective pain level - at the limit - of about 4, and was able to resist Dr. Mishra's attempt to pull down my upturned hand with a pain level of 3. During my first visit, I was only able to exert 65 pounds before I hit the wall (of pain) at level 9, and my resistance was lower and pain higher for the upturned hand exercise.

I was feeling pretty awful at the one-week mark, and was [still] rather disheartened at the one-month mark (though the email and comments on that post helped cheer me considerably). I have to say that I'm feeling much better at this stage - physically and emotionally - about my present condition and my future prospects for continued healing. I think Dr. Mishra is also encouraged at the progress in the last two months.

So, the current plan is to continue doing the stretching and theratube resistance exercises, hold off on resumption of more comprehensive strength training (for the right arm at least) and repetitive exercises (e.g., elliptical trainer with moving arms) and very gradually [continue to] extend my activities to accommodate more loading of the elbow.

I'll be going back for another followup at the six-month mark (second week in January), by which point I should have achieved about as much progress as I can expect from the treatment. I'm a little more optimistic about full - or nearly full - recovery, but there is still a chance I'll ultimately need surgery.

I've been in communication with a number of people who are considering or undergoing PRP treatments for their ailments. I wish you all the very best progress in your consideration and/or healing processes, and will do my best to honestly share my experience, strength and hope through exchanges of comments on this blog or via email.

[Note: I prefer communicating via blog comments, as many of the emails also contain gems of wisdom - and inspiring experience, strength and hope - that I'd like to share more broadly, i.e., through this blog, but I understand that some (many?) people are not comfortable posting public comments on blogs - er, perhaps particularly on this blog, given my recent tirades on spampliments - and so anyone who prefers email can also use the "Email me" link below my "thinking spot" photo at the top left.]

[Additional note (2007-10-11): NPR ran a story on Morning Edition today on how and why Patients Turn to the Internet for Health Information, based primarily on the recent Pew Internet study on E-patients With a Disability or Chronic Disease and a University of Wisconsin 17-year study called Comprehensive Health Enhancement Support System (CHESS) ... one of the programs in the similarly acronymed Center for Health Enhancement Systems Studies.

Here's an abstract from the Pew study:

About a fifth of American adults say that a disability, handicap, or chronic disease keeps them from participating fully in work, school, housework, or other activities. Half of those living with a disability or chronic disease go online, compared to 74% of those who report no chronic conditions. Fully 86% of internet users living with disability or chronic illness have looked online for information about at least one of 17 health topics, compared with 79% of internet users with no chronic conditions.

Those with chronic conditions are more likely than other e-patients to report that their online searches affected treatment decisions, their interactions with their doctors, their ability to cope with their condition, and their dieting and fitness regimen.

My decision to seek PRP treatment for my elbow was due to chronic tendonitis / tendinosis. I didn't do all that much research on the Internet (compared to other things I research), but since Dr. Mishra offers an alternative treatment (to surgery), is located very close to where I work, and is a blogger himself (!), I decided to visit him. I did get second (and third) opinions, from the doctor I'd seen for earlier episodes of elbow "flare ups", and from one of my cousins, who is an orthopod, and both agreed that non-surgical intervention was generally preferable over surgical intervention, and PRP seems to offer a reasonable cost/benefit ratio (based on how little we know yet on its long-term efficacy from larger-scale trials).

The people who have contacted me through email and comments on my blog posts have clearly done far more online research - and in many cases, suffered more and longer from chronic conditions - than I have ... and, of course, I'm not quite sure how much online research has been conducted by other readers of my PRP-related posts. In any case, I think we offer, collectively, a number of data points to corroborate the Pew findings.

I can't find the CHESS study referenced in the NPR story, but I did find another one that is interesting and somewhat relevant (and also related to my recent rant on fundamentalism in a post on Blessed Unrest), Effects of prayer and religious expression within computer support groups on women with breast cancer (press release), where they found:

As hypothesized, writing a higher percentage of religion words was associated with lower levels of negative emotions and higher levels of health self-efficacy and functional well-being, after controlling for patients' levels of religious beliefs. Given the proposed mechanisms for how these benefits occurred and a review of the support group transcripts, it appeared that several different religious coping methods were used such as putting trust in God about the course of their illness, believing in an afterlife and therefore being less afraid of death, finding blessings in their lives and appraising their cancer experience in a more constructive religious light.

I do not know the religious beliefs of the scientists who conducted the study (or other studies purporting to find a link between prayer and health), but as scientists, we have to be extra careful to not fall into the very human trap of seeing what we want to see (particularly when trying to study others' behavior that I believe amounts to seeing what they want to see). The New York Times ran an article on "Long-Awaited Medical Study Questions the Power of Prayer" last March reporting an American Heart Journal study - "Study of the Therapeutic Effects of Intercessory Prayer (STEP) in cardiac bypass patients: A multicenter randomized trial of uncertainty and certainty of receiving intercessory prayer" - that reports intercessionary prayer - praying for someone else's health (without their knowing about it) - has no measurable impact on the recipient of that prayer. What's interesting in the CHESS study (to me) is that it looks at the impact of prayer on the sender vs. receiver (or subject vs. object) of prayer - the person who is praying ... and although I don't know of any scientific justification for this, I do believe in  the power of positive thinking (and speaking (and writing)) ... which is why I so often find myself preaching what I want to practice, if not praying about it.]

[Yet another update (2007-10-12): Another study verifies the power of positive thinking:

Research is showing the power of expectations, that they have physical -- not just psychological -- effects on your health. Scientists can measure the resulting changes in the brain, from the release of natural painkilling chemicals to alterations in how neurons fire.

Among the most provocative findings: New research suggests that once Alzheimer's disease robs someone of the ability to expect that a proven painkiller will help them, it doesn't work nearly as well.

It's a new spin on the so-called placebo effect -- and it begs the question of how to harness this power and thus enhance treatment benefits for patients.

"Your expectations can have profound impacts on your brain and your health,'' says Columbia University neuroscientist Tor Wager.

The report referenced above contains yet another link to a study reporting that optimists live longer, but I think I've done [more than?] enough lateral drifting for one post.]

An update on my elbow, one month after Platelet Rich Plasma (PRP) treatment

I had my one-month followup visit with Dr. Mishra today, to review progress since undergoing a platelet rich plasma (PRP) treatment for chronic elbow tendonitis (or, based on an earlier comment, tendonosis) on July 12. I'd posted an update at the 1-week mark, and given all the comments I've received on the blog and via email, I wanted to post an update at the 1-month mark (well, the 5 1/2 week mark, technically speaking).

At this point, my right elbow feels pretty much like it did before the treatment - normally very little pain, a dull ache that starts after even light exercise (e.g., just standing / walking around for 20 minutes with the elbow unsupported ... or typing / mousing for that long), and occasional very sharp pain when I pick up something too heavy or otherwise overextend the elbow. I've regained most if not all of the flexibility in my elbow, e.g., I can now touch fingers from both hands with arms crossed diagonally behind my back, and can use my right hand for eating, drinking (though not my 20 ounce coffee mug) and brushing my teeth - though I'm still using the floss sticks. I can also wash and [towel] dry my hair with relatively little discomfort.

I confessed to Dr. Mishra that I had not followed some of the recommendations he and/or his assistant, Amy, had made on both specific activities and general actvities. They had recommended against taking both the dune buggy tour and the jet boat tour on our recent family vacation down the Oregon coast, as well as prolonged driving; I did all of the above. They had also recommended that I slow down on my typing speed (and duration), which I did, but only for the first two weeks - I suspect I'm back up to my normal speed, which is probably somewhere in the range of 80-100 wpm. I also did some vacuuming around the house yesterday, which, although they did not specifically recommend against it, I knew would not be good for my elbow - and Dr. Mishra confirmed that vibration, in general, is bad, and recommended that I not do more vacuuming for a while. I have, however, been diligent about avoiding anti-inflammatory medications and have been pretty good about doing the gentle stretching exercises.

Dr. Mishra said it is not at all uncommon for the condition of a PRP-treated elbow to be at the same level - or even slightly worse - at the one-month mark after treatment as it was prior to treatment. He re-iterated earlier recommendations (especially about the typing - so I'm going to try to keep this short), and I have started some theratube strengthening exercises. I'll have another followup visit on September 24, after which I'll post another update.

I'm glad that what I was interpreting as a lack of progress is not necessarily indicative of failure of the procedure. I have to say that during the vacation, I was feeling sad about not being able to so much ... though in writing this, I'm a bit embarrassed, as I know many other people have far more extensive disabilities (or, I suppose I should say, challenges). I still feel a bit disheartened, but writing this has been therapeutic - as has been the support offered through comments and emails - and so I will do my best to practice acceptance.

Update, 2007-08-23:

Pete sent me a note with a link to a Runner's World forum topic on My Platelet Rich Plasma Prolotherapy Journey (so far), started 24 May 2007, detailing a series of ups and downs with a PRP injection for knee tendonitis - including the ability to run 5 miles 3 days after the injection (!) - and ending with a report of 100% recovery on 15 August 2007. I'm glad to read of both the eventual success, and the ups and downs that were part of the journey, but I am a bit confused about the conflation of PRP and Prolotherapy, which I'd thought were different procedures. Clearly I have much to learn (and experience). [In a followup note, Pete sent me a link to the Prolotherapy Nashville page, along with some commentary that suggests that Prolotherapy is the more general term for injecting a specific substance - which may be saline, glucose or PRP - into the region around an injured ligament or tendon in order to stimulate healing. (Thanks^2, Pete!)]

Mark sent me a note detailing extensive experiences with various treatments that included an overuse of Cortisone; he now urges people to avoid the use of Cortisone. Fortunately, the doctor's I've seen about my elbow problems over the years have all been averse to using Cortisone, but I did have two Cortisone injections, and one of them was effective (for a while). I wanted to pass along Mark's (and my doctors') recommendations to avoid using Cortisone, as it is a complicating factor in the potential efficacy of PRP.

While I'm on the topic of avoidance, I'd meant to include a few recommendations for things I would have liked to avoid more (well, things I might have avoided more ... clearly, these are things I like), in the course of the healing process, if I were a bit more disciplined. I already mentioned [not] avoiding prolonged or fast typing [... he types, quickly]. Another strategy is to not buy a new 10-megapixel digital SLR camera during the recovery period. Holding the camera for shooting photos during our recent family vacation along the Oregon coast, resulted in significant pain, but I kept repeating the procedure many, many times, reveling in my renewed appreciation for [digital] photography. Another thing I wish I was more disciplined about is avoiding handshakes, at least with the right hand. I was pretty good about this during the first week, but the social discomfort I feel in reaching out with my left hand - or giving a less than firm handshake with my right hand - often overcomes my good sense about protecting my elbow. I still feel sharp pain during - and lingering pain after - firm handshakes. Another area in which I've not been able - or willing - to be more disciplined is [elbow] safe sex. I realize there are many, er, variations available, but [for me], it just is not a "hands off" (or "hand off") activity. My wife, of course, is far more disciplined than I am - fortunately, she doesn't read my blog, or I might get some extra, unwanted help, in practicing greater discipline in this dimension. In general, It seems that any activity that involves the use of the right arm in which I typically enter a flow state (typing, photography, sex) is a candidate for avoidance ... or perhaps more mindful attention.

Progress Report on Platelet Rich Plasma (PRP): Week 1

It's been a little over a week since my platelet rich plasma (PRP) injection for chronic tendonitis; as with my [blog posts about] my wife's anal cancer treatment (which was successful, as far as we can tell, having recently passed the two year milestone of being cancer-free), I've received email and other inquiries about the treatment and how my post-treatment experience is going, from people suffering from other types of tendinopathy (Dr. Mishra's web site suggests PRP can also be used for the treatment of Rotator Cuff, Patellar and Achilles tendinopathy, and his blog chronicles the use of PRP for a variety of disoreders). In case my experience may be of interest / use to others, I've decided to report on a few of my observations, insights and experiences at the end of my first week.

First of all, I neglected to mention that the doctor and his assistant initially neglected to mention that the treatment is not effective if it is administered within two weeks of the use of Ibuprofen (and I think aspirin, which I never use, and possibly other medications I never use), due to its adverse impact on blood thickness. Since this information was not provided at the outset, we had to abort our first scheduled date of treatment. And since patients are advised against flying for 7 days after the treatment, due to the increased risk of blood clotting (which they did initially mention), my travel schedule resulted in having to postpone treatment for 2 months.

The treatment itself was relatively painless - I felt a little burning when the local anaesthetic (Lidocaine) was injected, and a little pressure when the PRP was injected, but that was all. The main problem I had was that I often get lightheaded whenever a needle pierces my skin - I'm not conscious of any fear, but it happens every time - so I had to lie down for the procedure.

The rest of the day (afternoon) and the next day, I refrained from any activity. I felt no pain the first day, but did feel some pain the second day. I took some Vicodin that day, but have since felt relatively little pain - except when I forget to be careful with my elbow - and have taken very little pain medication (acetaminophen).

The primary ongoing challenges are stiffness and reduced range of motion, but these are diminishing over time. I've been doing some gentle stretching exercises throughout each day, and was able to start using my right hand for brief, non weight-bearing tasks after a few days. I was able to bend my arm 90 degrees by Thursday, and can now touch my nose. I started using my right hand for typing again on Thursday, but my arm feels fatigued quickly, and so I've cut back considerably on typing (in general) ... er, and I did not actually catch up on much reading, but that was for other reasons having to with preparations for a big internal launch of next generation proactive displays on Thursday ... about which I'll write separately (though a preview of our proactive display plans can be found on SlideShare.net).

Among the tricks, tools and [other] behavior modifications I found helpful - bearing in mind that I'm right-handed and the PRP injection was in my right elbow - were

• Switching from briefs to boxers (for the first week) ... reminding me of a Seinfeld episode


• Wearing sandals (socks and shoe ties would be difficult), polo shirts (buttons, especially near the top, would be difficult) and cargo pants (with extra pockets on each side that are easily reachable) ... of course, this is my typical "business casual" attire, anyway


• Extra pillows to prop my arm up while sleeping


• An electric toothbrush and dental floss picks


• Using a pump dispenser for soap and shampoo (actually, I didn't do this, but wish I had)


• Eating more sandwiches, wraps, pizza and other foods that do not require the [coordinated] use of silverware


• Making greater use of the Bluetooth earbud for my phone (my most painful moment so far has been to reach up to scratch my nose with my right hand while holding my phone to my ear with my left hand)


• Renting a car with a pushbutton [keyless] starter for the week; in my case, this was a Nissan Altima from my favorite rental car service, Enterprise Rent-A-Car

I'll post another update when there is more significant progress to report. Meanwhile, if others have questions or other observations, insights and experiences to share, please feel free to comment.

Mending Tendonitis via Platelet Rich Plasma (I hope)

I have been suffering for the past several months with the 3rd episode of tendonitis in my right elbow in 3 years. The first episode occured in November 2004 after excessive raking - I spent every waking moment for 2 consecutive dry days raking the wet leaves that had fallen over several rainy weeks from the Bigleaf Maple trees in our yard. After waiting several weeks for the pain to go away, I started several weeks of physical therapy, eventually coupled with several weeks of acupuncture - neither of which had significant effect (I was told that 30% of people have neuroreceptors that are not receptive to accupuncuture treatment, and I was likely a member of that minority); a cortisone shot finally resolved the problem in the summer of 2005.

The next episode occured in February 2006, when I joined some other fathers in running an informal baseball training clinic for our boys, who would be soon trying out for Minors in Woodinville Little League. I threw pitches in a batting cage for over an hour, after which my right arm felt like rubber ... after which my right elbow felt a great deal of familiar pain. This time, I thought I'd cut to the chase, and started with the cortisone shot. Unfortunately, this has no effect, so I tried physical therapy, but that had little effect, either. Finally, I went to see Becky Beveridge, of Feel the Knead Massage Therapy in Duvall, WA, who practices a rather unique style of massage she somewhat uneuphemistically calls "search and destroy" (as contrasted with the school of "fluff and buff" massage) - and in one session, the pain was gone.

The latest episode started in October 2006, shortly after joining Nokia Research Center Palo Alto. I suspect that the trigger was some combination of a new computer (IBM Thinkpad with a TrackPoint), a new physical workplace environment (Steelcase furniture with Herman Miller Aeron chair), and the inevitable stress that accompanies any significant life event, even one that is positive and welcome - actually, all of these were welcome developments, as I'd missed the ThinkPad + TrackPoint, Steelcase furniture and Aeron chairs I'd enjoyed at Accenture Technology Labs, as well as the opportunity to actually earn money while doing work that I love. Perhaps the stress of the long commute was a factor.

In any case, this time, I started with Becky, but despite three treatments, there was little change. I've been so engaged in my work during the weekdays, that it took me a long while to find - or make - the time to find a new doctor (now that I was spending weekdays in Palo Alto). I wasn't sure how to find a good doctor, but I'd walked by the Agile Physical Therapy office many a time on my way to / from lunch on California Avenue, and figured they would probably be able to recommend good doctors.

As it turns out, one of the doctors they recommended was Allan Mishra, an orthopedic surgeon at the Menlo Clinic who specializes in tendon disorders, and who is pioneering a new, relatively non-invasive, treatment for chronic tendonitis, using Platement Rich Plasma (PRP). The treatment involves withdrawing blood, separating the platelet rich plasma from the platelet poor plasma, and injecting the PRP into the injured area, which stimulates growth factors in the blood to help regenerate and repair the tissue in that area. More details can be seen in a 5-minute video that Dr. Mishra has posted on YouTube (!):

[He also has a blog (!!)]

The new treatment is not [yet?] FDA-approved, and I'll be paying for it out-of-pocket (and, unfortunately, we've never played the HSA game). However, the level of expected disability is lower than surgery, and the expected recovery time is shorter, and so I'll be able to type two-handed again sooner ... and avoid some of the other risks inherent in surgery (not that the PRP treatment is without attendant risks).

I'll be undergoing the procedure at noon today, and there will still be a period of at least a few weeks where I'll be avoiding or significantly reducing the use of my right arm, and so I'll likely be reducing the frequency and length of blog posts (and other forms of written or typed communication) for a while. Perhaps this will give me a chance to catch up on some reading...