British Columbia Medical Journal, October 2010 issue Please download or visit this entire issue online at http://www.bcmj.org/october-2010

1. worksafebc
Research team explores new bone and tendon-related treatments
Platelet-rich plasma offers Shock therapy thought to One cause of shoulder
mixed success in treating ease pain from calcified pain is calcific rotator cuff
tendinopathies supraspinatus tendinopathy
tendinopathy, which occurs
The concept of using growth factors One cause of shoulder pain is calcific
contained in activated platelets to rotator cuff tendinopathy, which occurs in 7% to 17% of rotator
help wound healing dates back to the in 7% to 17% of rotator cuff tendinopa- cuff tendinopathies.
early 1980s. More recently, the use of thies. Extracorporeal shock wave ther-
platelet-rich plasma (PRP) to treat apy (ESWT) has been promoted as an
various musculo skeletal disorders, alternative to surgical intervention in experts have demonstrated a lack of
including tendinopathies, has increas- treating rotator cuff tendinopathy that agreement regarding the diagnosis of
ed tremendously. fails to respond to conventional and fracture nonunions.
Tendon healing is a complex pro- more conservative therapies. While While ultrasound has been applied
cess involving many growth factors, the mechanism is still unclear, this in treating fractures for half a century,
such as platelet-derived, transform- outpatient procedure is thought to pro- its role in fracture healing is not
ing, vascular endothelial, insulin-like, vide long-lasting analgesia and stimu- well understood. In January 2010, the
and epidermal growth factors, which late the healing process. WorkSafeBC Evidence-Based Prac-
are detected in higher concentrations In June 2010, the WorkSafeBC tice Group investigated the effective-
in PRP. To date, the respective role of Evidence-Based Practice Group inves- ness of Exogen low-intensity ultra-
each type of growth factor requires tigated the effectiveness of ESWT, sound in treating fracture nonunion
further exploration. As well, recent using low- and high-level energy shock and found three high-quality system-
evidence suggests varying concentra- waves to treat calcific supraspinatus atic reviews12-14 and one large case
tion levels of these growth factors in or rotator cuff tendinopathy in gener- series (n = 1317)15 that showed as fol-
PRP, depending on the protocol and al. Their findings included two sys- lows:
devices used to spin the blood. tematic reviews, one of high quality6 • No high-level primary studies exist
In April 2010, the WorkSafeBC and one of low quality,7 three low- to provide evidence of the effective-
Evidence-Based Practice Group con- quality RCTs,8-10 and one low-quality ness of low-level ultrasound.
ducted a systematic literature review case-control study.11 This included • Low-level evidence, including large
of the effectiveness of PRP in treat- some high- and low-quality evidence case series, showed that low-level
ing tendinopathies. They found five to suggest high energy ESWT can ultrasound is effective as an adjunct
studies of varying quality and design provide pain relief and increased func- to good immobilization, especially
investigating the application of PRP tion, as measured by the Constant- when provided by an external
in treating chronic patellar tendinosis1 Murley score, among patients suffering immobilizer.
and chronic elbow tendinosis,2 during from calcific rotator cuff tendinopa- • Low-level ultrasound may be effec-
arthroscopic rotator cuff repair,3 dur- thy. There was no evidence on the tive among patients aged 31 to 60
ing Achilles tendon surgery to pro- effectiveness of ESWT in treating with long bone or scaphoid frac-
mote healing,4 and treating Achilles noncalcific rotator cuff tendinopathy. tures; who had comorbid illnesses;
tend ino pathy. 5 Lower-quality and who had been treated with other
lower-level studies 1-4 showed the Low-intensity ultrasound for drugs, such as steroids, NSAIDs,
effectiveness of PRP in treating vari- nonunion fractures appears anticoagulants; or who are current
ous tendinopathies. However, the only effective for some smokers.
available high-quality evidence show- Fracture healing is a complex process Other adjunct treatments, yet to
ed that PRP injection compared to involving various factors that need to be tested for effectiveness, are also
saline injection did not result in sig- occur at a specific time and place. available. These include pulsed elec-
nificant improvement in pain and US data show up to 10% of healing tromagnetic field stimulation, direct
activity.5 These studies could not dis- fractures develop delayed union, current or capacitative coupling, ex-
count the value of co-interventions. and a significant proportion of these tracorporeal shockwave stimulation,
become nonunions. At present, some Continued on page 416
www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 391

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advertiser
Continued from page 414 Continued from page 413
index
early screening in high-risk CKD
Core-Plus Plan patients, as anergy may be less of
reminder a confounder in those with less
The BC Medical Association
thanks the following advertisers
The open enrollment period for the advanced disease. Once LTBI
for their support of this issue of
Core-Plus Plan under the BCMA infection is established, prophy-
the BC Medical Journal.
Health Benefits Trust Fund is under- lactic therapy should be consid-
way. The deadline to enroll in this pro- ered in consultation with TB con-
AIM Medical Imaging ............... 425
gram, or to make changes to your cov- trol and the patient’s personal
erage if you are already participating, physicians. As always, an ounce
BC Association of
is 31 October 2010. New coverage or of prevention trumps a pound of
Clinical Counsellors ................ 384
changes to existing coverage for cure.
members who submit the required Cambie Surgery Centre/
plan documents by the deadline will Specialist Referral Clinic ..... 423
be effective 1 January 2011. cohp
If you have any questions regard- Carter Auto ........................................ 422
ing the open enrollment period or the Continued from page 411
plans offered under the BCMA Health Canada’s Natural Health Products General Practice
Benefits Trust Fund, please visit www Directorate places Canadians in Service Committee
.bcma.org/hbtf or contact an HBTF harm’s way by failing to prevent ...................385, 388, 390, 416, 421
Administrator: exaggerated health claims and by
Cory St Jean exposing consumers to unneces- Guidelines and Protocols
Toll free: 800 665-2262 ext. 2865 sary health risks. Given that med- Advisory Committee ............... 389
Direct: 604 638-2865 ical claims made on behalf of
cstjean@bcma.bc.ca NHPs typically exceed the evi- Interior Health ................................. 419
Darlene Laird dence of medical benefit, and that
MCI Medical Clinics Inc. ........ 387
Toll free: 800 665-2262 ext. 2818 significant safety issues with vari-
Direct: 604 638-2818 ous NHPs continue to be discov- Optimed ............................................... 386
dlaird@bcma.bc.ca ered upon proper scientific test-
—Sandie Braid, CEBS ing, many Canadians will wonder Robson Helimagic ........................ 424
Assistant Director, BCMA Insurance if a near-billion-dollar bonanza to
industry is worth the price. Society of Specialist
—Lloyd Oppel, MD Physicians and Surgeons ...... 388
Chair, Allied Health Practices
worksafebc Committee Speakeasy Solutions .................... 424
Continued from page 391 References
Westgen ............................................... 385
and orthobiologics, especially the 1. Geddes J. Problems in the natural
Wickaninnish Inn .......................... 387
bone morphogenic protein (BMP)-7. health products aisle. Maclean’s 3
Full documents and other system- October 2009. www2.macleans.ca/
atic reviews can be downloaded from 2009/10/03/problems-in-the-natural-
www.worksafebc.com/evidence. health-products-aisle/ (accessed 23
—Kukuh Noertjojo, MD, August 2010).
MHSc, MSc 2. Gavura S. Health Canada gets out a
—Craig Martin, MD, MHSc big rubber stamp. Science-based
WorkSafeBC Evidence- Pharmacy [blog] 15 July 2010. http://
Based Practice Group sciencebasedpharmacy.wordpress
.com/2010/07/15/health-canada-
References g e t s - o u t - a - b i g - r u b b e r- s t a m p /
References are available by calling Carmen (accessed 23 August 2010).
Prang at 604 244-6224 or toll-free 1 800 967-
5377, extension 6224 or carmen.prang@
worksafebc.com or online at www.bcmj.org.
416 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org