03 April 2012

Science of Baseball: Zach Britton and Platelet Rich Plasma Injection

It was reported that Zach Britton was going to undergo platelet rich plasma injection on his shoulder to treat inflammation.  This event has been covered by Brittany Ghiroli and Andrew Gibson.  Britt's post includes a couple interviews and focuses on a pedestrian understanding of the process, why you might choose to do this over a cortisone injection, and its efficacy.  It is a solid mainstream article on PRP.  You should click on the link above and read it.  Andrew's article, in a way, provides greater context to the procedure and you should read that one as well.

I have been asked to write on this by a few of my readers as I tend to write about scientific matters in baseball and this sort of thing speaks to my training.  My research at the UMD-B's Medical School was focused on reproduction and DNA damage, but my class room training was a bit broader.  This should clue you in on my perspective in that how I typically see things differently than a medical doctor.  The best way I can explain it is that from my experience a medical doctor acts more as an advocate for the patient than as a strict scientist.  This means that they tend to believe in the benefit of procedures before the science can weigh in on the matter.

Another comparison is the PED issue in baseball.  There are the advocates (e.g. players, gym rats) and the science.  Sometimes the advocates get ahead on a specific issue, such as steroids improving athletic performance.  When the advocates get ahead of the curve though, they tend not to fully understand the procedure and can misapply it.  Thus, a poorly understood application of steroids could result in worse performances.  There is actually still much debate as to how effective steroids were for hitters generating power as well as other purported usage.  There is still misinformation out there as to how steroids affects head size and eye sight.  Science has largely caught up with this treatment and how to effectively use it in a clinical setting, but that often poorly translates as the message is transcribed into the gym locker room.

I do not see myself as an advocate.  You probably already know this from my previous writings on PEDs.  I like to see solid proof of something working.  This means getting into the nuts and bolts, understanding the science with a critical view.  After a quick overview, I will delve into some more recent journal articles.

Although summarized in Britt's and Andrew's articles, I think it might be beneficial to actually see an application of PRP.  In the video below, a physician uses the treatment for a patient with tendinitis in the elbow.  Tendinitis is an acute injury to the tendon that is accompanied by inflammation. 



For Zach Britton, the inflammation is in his shoulder as opposed to his elbow. With the information we have at hand, it is difficult to know exactly what kind of damage has occurred.  In fact, the physicians are probably unsure as well due to not being able to observe any damage.  I think the two most likely issues would be minor tearing in his rotator cuff or a small lesion in his labrum.  It might also have something to do with the biceps tendon, but I think that would be less likely than the other two.  With a minor injury, it may be difficult to determine what exactly is the cause.  As you can see, it is a rather busy joint.

The few articles I will be reviewing focus on injuries far more severe than what Britton currently has.  There really are no good studies that evaluate the efficacy of PRP on minor injuries.  The scant research available has been focused on major injuries, such as rotator cuff tears requiring surgery and ruptures of the Achilles tendon.  I will focus on two recent ones: a study on rotator cuff repair and another on a comparison between different injection techniques.  I will then follow up with my own thoughts on the treatment.

Platelet-Rich Plasma Augmentation for Arthroscopic Rotator Cuff Repair
Castricini et al. AJSM

One thought about the slow healing process with any sort of tendon tear is that the tissue is poorly vasculated.  In other words, little blood is getting to the area.  Blood carries all sorts of proteins and other chemicals that aid in the healing process.  The hypothesis is then that by concentrating the components of the blood largely responsible for healing (e.g., insulin growth factor, thrombin) and then applying them to the surgical site that it would then result is greater healing.

In this study, they are not looking at cases similar to Zach Britton's.  They are looking at tears that required surgery.  In this study, 88 patients were included with 45 given PRP in the form of a fibrin matrix.  Basically, you use a polymerized fibrin matrix so that you are able to physically connect it to the repaired area.  This is different from Britton's treatment where his PFP is not in a fibrin matrix and is instead directly injected at the site of inflammation.  The PRFM look like this:

What they found was that after 16 months, there was no difference between the group that was given a PRFM and those that did not have that aspect of the treatment.  However, the two caveats would be that these individuals were not athletes and rate of recovery within those 16 months was not evaluated.  Another, more recent, article looked at the same procedure with a 12 month follow up and found no difference between groups of similar treated patients with the lone exception that the PRFM group had a greater likelihood for retears.  These fall in line with the perspective of the physician that Britt interviewed.  However, another study that would have done better with a bit larger of a sample size found that PRP (they injected the PRP and then used sterile air to form a clot) may be useful for low grade tears, but not more significant ones.

Again, Britton does not fit in any of these categories.

Growth Factor-based Therapies Provide Additional Benefit Beyond Physical Therapy in Resistant Elbow Tendinopathy
Creaney et al. 2011 BJSM

This article focuses on patients who have not found any success with traditional physical therapy techniques to heal their elbows.  The researchers decided to compare PRP with ABI.  PRP again is the injection of concentrated platelets and growth factors while ABI is whole blood injection.  There was no control, placebo control, or comparison to a well known technique, such as administration of cortisone.  The researchers felt it was not ethical to have a group in the study that would not receive any treatment.  They found that both PRP and ABI produced similar results.  They both had a success rate around 70% (success defined as improvement in a Tennis Elbow Evaluation metric) over the course of six months (injection was at 0 and 1 month).  This looks like a solid result, but it hurts not having a control or traditional treatment comparison.

Conclusion
One of the first rules in treating someone is to do no harm.  This is where I divide PRP from something like hGH.  I have a difficult time seeing how currently applications of PRP could be dangerous to the patient.  I think there is also some data out there that suggests that PRP might be of some use to the healing process.  There are issues with knowing whether or not it works or how to use it best.  For instance:
  • No information on the level of concentration that is important for creating the PRP fraction,
  • No observations of the mechanisms of action for this treatment,
  • Few randomized studies and the existing randomized studies do not show a clear benefit, and
  • No consensus on injection site or frequency.
Treatment mechanisms in the past have been relatively simple to explore with increasing red blood cells, anabolic steroids, catabolic steroids, or hGH.  As I have covered before, responses to mixtures is a bit more difficult to measure.  The most interesting work in PEDs right now is work on hGH combined with testosterone (which similar to hGH alone does not seem to improve athletic performance).  With platelets, you have a much more complex set of growth factors and other proteins.  There remains great uncertainty.

It might work for Britton, it might not.  We really do not know.  If he gets betters, it does not mean it worked.  If he gets worse, it does not mean it didn't work.

02 April 2012

News and Notes

by Tom Peace

The Orioles are five days away from Opening Day and the ballclub still needs to make some roster moves. Here are the moves the have made in the last week to get ready for the season.

The long wait is over on who will be the Opening Day starter for the Baltimore Orioles. Jake Arrieta was given the nod from manager Buck Showalter to take the hill this Friday against the Minnesota Twins.  Arrieta started in 4 games this spring for the ballclub going 1-0 with a 6.14 ERA.  Though, the right-hander stuck out 12 batters and only walked 4.

Starting pitcher Chris Tillman was optioned to AAA Norfolk. The right-hander had moderate spring training. According to Orioles.com, the Orioles want him to be a starter and get some more innings down on the farm before being brought back up to the majors.

The Orioles’ designated Dana Eveland, 28, for assignment last week after going 1-2 with a 3.46 ERA in six games (three starts). The Orioles then claimed utility infielder Zelous Wheeler off waivers from the Milwaukee Brewers.

Baltimore acquired Eveland in a trade during the Winter Meetings back in December. Wheeler, in five Minor league seasons batted .271 and had a .371 OBP. The young third baseman is another example of Executive Vice President Dan Duquette going after high on-base percentage guys.

The chances of non-roster invitee, catcher Ronny Paulino making the 25 man Opening Day roster improved this past week as Taylor Teagarden was placed on the disabled list.  Teagarden hasn’t played in a game since March 6th and will have a second epidural in his lower back.

AL Team FIP by Pitching Postion

Keep an eye on the y-axis.  It changes from one graph to the next.  Also, the order of the teams change as well except for the Orioles who ranked as having the worst pitching by slot for every slot.

First Slot


Second Slot


Third Slot


Fourth Slot


Fifth Slot


As a little extra...here is the Orioles xWAR vs the World

Click to Enlarge

30 March 2012

ESPN 3 Who to Watch: Weekend of March 30 to April 1, 2012

by Jeremy Strain

References to prospect rankings are generally taken from the Top 100 Draft Prospect preseason rankings at Baseball America.

FRIDAY

3/30 6:00 PM EDT Virginia Tech vs. #4 Florida State
Florida St. features 2012 draft hopefuls Justin Gonzalez, who is having a slow start to the year, James Ramsay and Jayce Boyd. Virginia Tech features fringe top 100 prospect Andrew Rash.

3/30 6:30 PM EDT #8 Miami (FL) vs. Clemson
Number 8 Miami is led by early-round draft prospect C Peter O’Brien, as well as RP E.J. Escinosa, and SS Stephen Perez. Clemson features top 2012 prospects P Kevin Brady and 3B Richie Shaffer, as well as a few interesting follows such as Jason Stolz and P Kevin Pohle.

3/30 6:30 PM EDT Virginia vs. #22 North Carolina State
Virginia features RP Branden Kline and SS Stephen Bruno who are prospects for the draft this year, and while NC State doesn’t have any BA Top 100 players it does have a pair of young players worth watching in P Carlos Rodon and C Brett Austin.

3/30 8:00 PM EDT #3 Arkansas vs. #14 LSU
Third ranked Arkansas features top 2012 draft prospects Nolan Sandburn and P DJ Baxendale, and 2013 top draft prospects Dom Ficocciello and Ryne Stanek. The Tigers boast one of the top prospects in the 2012 draft -- P Kevin Gausman -- as well as SS Austin Nola.

SATURDAY
3/31 1:00 PM EDT Duke vs. #21 Georgia Tech
Duke features a top pitching prospect in Marcus Stroman, whereas Georgia Tech features P Buck Farmer, as well as OF prospects Brandon Thomas and Kyle Wren.

3/31 1:00 PM EDT Alabama vs. Tennessee
Alabama has OF Taylor Dugas and P Ian Gardeck who are in the latter part of the 2012 top 100 prospects while Tennessee has no prospects in Baseball America’s top 100 list this season.

3/31 4:00 PM EDT #7 Kentucky vs. #18 Georgia
Kentucky features 2012 prospect, OF Brian Adams, while Georgia has two pitchers in the latter half of BA's list in Michael Palazzone and Alex Wood.

3/31 4:00 PM EDT #10 South Carolina vs. Vanderbilt
South Carolina boasts a lineup featuring draft hopefuls, 1B Christian Walker, OF Adam Matthews, P Matt Price, and OF Evan Marzilli. Vandy features P Sam Selman, who is having a rough year, and OF Michael Yastrzemski, the grandson of the great Carl Yastrzemski. Tyler Beede is a young player to watch for future years.

3/31 4:00 PM EDT #8 Miami (FL) vs. Clemson
Number 8 Miami is led by top draft prospect C Peter O’Brien, as well as RP E.J. Escinosa, and SS Stephen Perez. Clemson features top 2012 prospects P Kevin Brady and 3B Richie Shaffer, as well as a few interesting follows such as Jason Stolz and P Kevin Pohle.

3/31 6:00 PM EDT Virginia Tech vs. #4 Florida State
Florida St. features 2012 draft hopefuls Justin Gonzalez, who is having a slow start to the year, James Ramsay and Jayce Boyd, while Virginia Tech features fringe top 100 prospect Andrew Rash.

3/31 6:30 PM EDT Virginia vs. #22 North Carolina State
Virginia features RP Branden Kline and SS Stephen Bruno who are prospects for the draft this year, and while NC State doesn’t have any BA Top 100 players it does have a pair of young players worth watching in P Carlos Rodon and C Brett Austin.

SUNDAY
4/01 12:00 PM EDT Miami (FL) vs. Clemson
Number 8 Miami is led by top draft prospect C Peter O’Brien, as well as RP E.J. Escinosa, and SS Stephen Perez. Clemson features top 2012 prospects P Kevin Brady and 3B Richie Shaffer, as well as a few interesting follows such as Jason Stolz and P Kevin Pohle.

4/01 1:00 PM EDT Virginia vs. #22 North Carolina State
Virginia features RP Branden Kline and SS Stephen Bruno who are prospects for the draft this year, and while NC State doesn’t have any BA Top 100 players it does have a pair of young players worth watching in P Carlos Rodon and C Brett Austin.

4/01 1:00 PM EDT Virginia Tech vs. #4 Florida State
Florida St. features 2012 draft hopefuls Justin Gonzalez, who is having a slow start to the year, James Ramsay and Jayce Boyd, while Virginia Tech features fringe top 100 prospect Andrew Rash.

4/012:00 PM EDT California vs. #25 Texas
Cal has a couple players in the top 100 in P Justin Jones and SS Tony Renda, and Texas counters with top prospect pitcher Hoby Milner. The Longhorns' projectable starter Sam Stafford is out for the season with a shoulder injury.