How ef­fec­tive are al­ter­na­tive ther­a­pies?

Many cy­clists are re­sort­ing to off­beat, un­proven ther­a­pies in a bid to re­cover from in­juries. Are they be­ing cured or conned? CW in­ves­ti­gates

Cycling Weekly - - Contents - Dr Nick Tiller

In­juries are part and par­cel of train­ing and rac­ing. Whether you’re a pro rider or week­end war­rior, pick­ing up an in­jury can mean weeks on the side­lines as your hard­earned fit­ness de­te­ri­o­rates. In the worst-case sce­nario, for a pro, liveli­hood and even ca­reer can be put in jeop­ardy. Des­per­ate to get back on track, more and more riders are tak­ing a chance on un­proven, weird and won­der­ful ther­a­pies that prom­ise to fast-track their re­cov­ery.

Pro­fes­sor Alex Faulkner, a re­searcher in the so­ci­ol­ogy of health­care at the Uni­ver­sity of Sus­sex, is in­ves­ti­gat­ing the use of such treat­ments in elite sport in theUK. “We found that doc­tors con­sciously take into ac­count the ‘be­lief sys­tem’ of full-time ath­letes, and many use homeopa­thy, re­flex­ol­ogy, chi­ro­prac­tic, and os­teopa­thy — in spite of weak sci­en­tific ev­i­dence for their ef­fi­cacy.

“One pro cy­cling ther­a­pist told us that the level of in­no­va­tion in bi­o­log­i­cal ther­a­pies meant that ‘the sci­ence will catch up’. Aver­sion to nee­dle-based ther­a­pies in cy­cling may con­tribute to in­ter­est in the al­ter­na­tives.”

Though these ther­a­pies may pur­port to be ‘revo­lu­tion­ary’ or ‘cut­ting-edge’, many of them are founded on hype and hope rather than solid sci­ence. Are cy­clists wast­ing their time and money on treat­ments that of­fer no real ben­e­fit?

Re­gen­er­a­tive medicine

Since the Thir­ties, doc­tors have been treat­ing mus­cu­loskele­tal in­juries us­ing re­gen­er­a­tive bi­o­log­i­cal pro­ce­dures called or­tho­bi­o­log­ics. These are sub­stances pro­duced nat­u­rally in the body which are har­vested and rein­tro­duced to pro­mote the heal­ing of bro­ken bones, in­jured mus­cles, car­ti­lage, ten­dons and lig­a­ments. There are var­i­ous treat­ments that fall un­der the um­brella term or­tho­bi­o­log­ics, sup­ported (or not) by var­i­ous de­grees of sci­en­tific ev­i­dence. Many pro ath­letes re­sort to these tech­niques, per­ceiv­ing them as cut­tingedge or even fash­ion­able, but what does the ev­i­dence say?

Bone grafts

Prob­a­bly the old­est of the or­tho­bi­o­logic treat­ments, bone grafts are used on breaks and frac­tures. At first glance not so dif­fer­ent from the du­bi­ous work of Dr Franken­stein who “col­lected bones from char­nel-houses” to build his mon­ster, the graft can be ex­tracted from var­i­ous lo­ca­tions (e.g. the pelvis), then im­planted at the site of in­jury to fill a void, help pro­vide struc­tural sta­bil­ity and even pro­mote re­gen­er­a­tion. Frac­tures of the col­lar­bone are com­mon among pro cy­clists, who de­mand a speedy re­cov­ery. Filippo Poz­zato, for ex­am­ple, broke his col­lar­bone in 2012, but was back in the sad­dle just days fol­low­ing surgery to place sec­ond in the Tour of Flan­ders.

And yet, the ev­i­dence for bone graft­ing is mixed, de­pend­ing on the na­ture and site of in­jury. A 2015 ret­ro­spec­tive study pub­lished in the Jour­nal of Or­thopaedic Surgery and Re­search stud­ied 58 pa­tients with slow-heal­ing clav­i­cle frac­tures. Al­though nearly all pa­tients in the sam­ple re­cov­ered, the 33 pa­tients re­ceiv­ing bone grafts re­cov­ered at a faster rate. In­deed, the re­search on bone graft­ing for clav­i­cle in­juries is gen­er­ally pos­i­tive.

De­spite the risk in­her­ent in all surgery, the costs are fairly mod­est, at £1,000£2,000. On bal­ance, then, bone-graft­ing is a rea­son­able av­enue of ex­plo­ration for the con­sul­tant and cy­clist look­ing to min­imise time out of the sad­dle.

Stem cells

Stem cells are a class of cells that are able to spe­cialise their func­tion for any given pur­pose. They can di­vide or self-re­new in­def­i­nitely, en­abling them to gen­er­ate a range of cell types from the lo­ca­tion where they are in­jected. Stem cells are usu­ally har­vested from the bone mar­row, in which they are most con­cen­trated, and then in­jected into the site of in­jury to pro­mote re­cov­ery.

One form of stem cell ther­apy, called bone mar­row as­pi­rate con­cen­trate (BMAC), pro­vides a good source of growth fac­tors that are thought to have an im­por­tant mus­cle-build­ing and anti-in­flam­ma­tory ef­fect. Treat­ments are ex­pen­sive, at £5,000-£6,000, but, more im­por­tantly, there are sev­eral risks and eth­i­cal con­cerns around stem cells.

All clin­i­cal pro­ce­dures must in­clude a care­ful anal­y­sis of the ben­e­fit-to-risk ra­tio. On the ba­sis of avail­able stud­ies, the risks in this case are not suf­fi­ciently off­set by the po­ten­tial ben­e­fits. Sev­eral re­cent sys­tem­atic re­views pub­lished in the re­spected Bri­tish Jour­nal of Sports

Medicine have called the prac­tice into ques­tion, high­light­ing the lack of firm ev­i­dence. The au­thors con­cluded that they do not rec­om­mend stem cell ther­apy for knee os­teoarthri­tis; no ev­i­dence was found for the ther­a­peu­tic use of stem cells for ten­don dis­or­ders. As such, this ap­pears to be an ex­pen­sive and risky pro­ce­dure with not nearly enough ev­i­dence in its favour.

Platelet-rich plasma (PRP)

PRP is per­haps the most pop­u­lar of the or­tho­bi­o­logic treat­ments. It works by us­ing a quan­tity of an in­di­vid­ual’s blood that con­tains a higher than nor­mal con­cen­tra­tion of platelets. About 60ml of blood is drawn from a vein in the arm,

and then spun in a cen­trifuge to separate the red cells from the blood’s other con­stituents. The platelet-rich por­tion is then care­fully in­jected at the site of in­jury, us­ing an ul­tra­sound probe to see im­ages at the mus­cu­lar level.

The platelets con­tain over 30 dif­fer­ent pro­teins, which are con­sid­ered po­tent in heal­ing. Nu­mer­ous stud­ies have as­sessed the ef­fec­tive­ness of PRP. In one ran­domised con­trolled trial, pub­lished in the Amer­i­can Jour­nal of Sports Medicine, 51 pa­tients with lat­eral epi­condyli­tis (ten­nis el­bow) ex­hib­ited sig­nif­i­cantly bet­ter im­prove­ments in pain and func­tion scores with PRP when com­pared to 49 pa­tients who re­ceived cor­ti­cos­teroid in­jec­tions. De­spite the en­cour­ag­ing re­sults, the study is not sup­ported by much other lit­er­a­ture. More­over, for in­juries at other sites (e.g. the ro­ta­tor cuff, knee and Achilles ten­don) the ev­i­dence for PRP is even less con­vinc­ing.

A 2014 re­view analysing the pros and cons of the avail­able strate­gies, as well as the paucity of qual­ity stud­ies, con­cluded that PRP can­not be rec­om­mended for rou­tine use. An im­por­tant con­sid­er­a­tion is that PRP was ini­tially banned by the World Anti-dop­ing Agency (WADA), though it has since been le­galised for treat­ing sports in­juries.

Ac­tove­gin

Sixty years of re­search has failed to iden­tify the ac­tive in­gre­di­ents of this ul­tra-fil­tered calf’s blood, though it is thought to con­tain steroid hor­mones and amino acids, which stim­u­late mus­cle re­pair, and Inos­i­tol phos­phate oligosac­cha­rides (IPO), which pro­mote glu­cose up­take.

Ac­tove­gin has re­ceived some me­dia at­ten­tion be­cause its cre­ator, Dr Hans-wil­helm Müller-wohlfahrt, so-called ‘Heal­ing Hans’, has worked with some of the world’s top ath­letes in­clud­ing Usain Bolt, Ron­aldo and Paula Rad­cliffe. You might re­mem­ber Ac­tove­gin as the prod­uct that Lance Arm­strong and the US Postal Team were caught try­ing to smug­gle across the French border in 2000.

Many of the clin­i­cal stud­ies have tested Ac­tove­gin on rats, and so the ev­i­dence is far from con­clu­sive. When look­ing at hu­man stud­ies and, specif­i­cally, data in com­pet­i­tive ath­letes, there is lim­ited ev­i­dence for its use in treat­ing mus­cle in­juries, and no ev­i­dence re­gard­ing per­for­mance-en­hanc­ing ef­fects. For this rea­son, the sub­stance has not yet made it onto the WADA list of banned sub­stances, ex­cept in very high con­cen­tra­tions.

Among the pub­lished stud­ies on Ac­tove­gin is a case re­port in the An­nals

of In­ter­nal Medicine which de­scribed ana­phy­lac­tic shock and mul­ti­ple or­gan fail­ure in a cy­clist fol­low­ing in­tra­venous ad­min­is­tra­tion of Ac­tove­gin. Al­though the pa­tient re­cov­ered, and it ap­pears to be an iso­lated case, the risks re­quire fur­ther ex­plo­ration.

Al­ter­na­tive ther­a­pies

Some­times re­ferred to as com­ple­men­tary medicines, these are a group of treat­ments that claim to have the pow­er­ful heal­ing ef­fects of mod­ern medicine — but without any of the as­so­ci­ated ev­i­dence or strin­gent sci­en­tific cri­te­ria. In fact, many of the ba­sic claims of these treat­ments run counter to fun­da­men­tal laws of na­ture.

Cup­ping

Sev­eral ath­letes at the Rio Olympic Games were pic­tured with cir­cu­lar bruises on their skin — the re­sult of an an­cient Chi­nese ther­apy called cup­ping. The pro­ce­dure in­volves the place­ment of small glass cups onto sore mus­cles or sites of in­jury. The cups are heated, caus­ing suc­tion on the skin, which is sup­posed to stim­u­late blood flow. That said, cup­ping was orig­i­nally, in East­ern prac­tice, de­signed to stim­u­late en­ergy flow along the body’s merid­i­ans, the en­ergy chan­nels cen­tral to tra­di­tional Chi­nese medicine.

The char­ac­ter­is­tic bruis­ing is caused by bro­ken cap­il­lar­ies and clot­ted blood. This con­tra­dicts the no­tion that cup­ping stim­u­lates blood flow. Pro­po­nents of cup­ping have mis­ap­pro­pri­ated sci­en­tific terms and con­cepts to cre­ate a pseu­do­sci­en­tific prac­tice that doesn’t ad­here to real-world prin­ci­ples.

The re­search into cup­ping is wholly neg­a­tive, with the higher-qual­ity stud­ies fail­ing to show any phys­i­o­log­i­cal ben­e­fits. Don’t be fooled by the en­dorse­ments from suc­cess­ful Olympic ath­letes; any pos­i­tive ef­fects are likely just placebo.

Traumeel

For years, ath­letes have been us­ing non-steroid anti-in­flam­ma­tory drugs (NSAIDS), such as ibupro­fen, to treat in­jury and re­duce in­flam­ma­tion. But with over­whelm­ing re­search

show­ing that NSAIDS can have se­ri­ous ad­verse ef­fects on the car­dio­vas­cu­lar, mus­cu­loskele­tal, gas­tro-in­testi­nal and re­nal sys­tems, the lat­est sci­en­tific rec­om­men­da­tion is to avoid NSAIDS dur­ing ex­er­cise.

This has been ex­ploited by the al­ter­na­tive ther­apy move­ment, which has re­sponded with Traumeel, a sub­stance mar­keted to treat sports in­juries, in­flam­ma­tion, and pain. The laun­dry list of nat­u­ral in­gre­di­ents in­clude Aconi­tum napel­lus, Ma­tri­caria re­cu­tita, Ar­nica and Echi­nacea, mostly in ex­tremely di­lute con­cen­tra­tions.

Sev­eral stud­ies sug­gest that Traumeel might be a rea­son­able al­ter­na­tive to NSAIDS for the treat­ment of mus­cu­loskele­tal in­juries, al­though the re­search is far from con­clu­sive. Fur­ther stud­ies are needed be­fore Traumeel can be con­fi­dently pre­scribed for in­jury man­age­ment. It is mar­keted as a home­o­pathic rem­edy, though tech­ni­cally home­o­pathic prod­ucts are so di­luted as to not con­tain any ac­tive in­gre­di­ents.

Acupunc­ture

An­other ves­ti­gial prac­tice from tra­di­tional Chi­nese medicine, acupunc­ture has gained wide­spread ac­cep­tance be­cause of its use in phys­io­ther­apy clin­ics around the world. The an­cient premise was to stim­u­late en­ergy flow along body merid­i­ans by spear­ing small nee­dles into the skin at acupunc­ture sites. As with many tra­di­tional ther­a­pies, the prin­ci­ples have now been retro­fit­ted to align with a less mys­ti­cal, more sci­en­tific-seem­ing con­tem­po­rary view­point.

One of the prob­lems with acupunc­ture is that there’s no plau­si­ble mech­a­nism of ac­tion. Some pro­po­nents ar­gue that pen­e­trat­ing the skin with nee­dles causes the re­lease of nat­u­ral pain-killers into the blood, re­leas­ing mus­cle ten­sion, but nei­ther has been clin­i­cally demon­strated. There are lit­er­ally hun­dreds of stud­ies in acupunc­ture and some ex­cel­lent sum­maries have been com­piled by Sci­ence-based Medicine (www. sci­ence­basedmedicine.org) and the NHS (www.nhs.uk).

Acupunc­ture may be anec­do­tally well sup­ported, but in the ma­jor­ity of high-qual­ity stud­ies its ef­fects rarely out­per­form place­bos. The small ben­e­fit shown in cer­tain stud­ies can­not be con­sid­ered clin­i­cally sig­nif­i­cant.

Ac­cord­ing to Dr Steven Novella, a neu­rol­o­gist at Yale Uni­ver­sity, acupunc­ture is not worth the risk or the cost: “Hu­man­ity should not waste an­other penny, an­other mo­ment, an­other pa­tient — any fur­ther re­sources — on this dead end.”

Conclusion

Hu­mans are hard-wired for tak­ing short­cuts; it served as a sur­vival ad­van­tage for our dis­tant an­ces­tors. In the mod­ern world, short­cut-seek­ing behaviour man­i­fests in our ob­ses­sion with sup­ple­ments, gad­gets, and quick­fix ther­a­pies for in­jury man­age­ment. Com­mer­cial pres­sure on ath­letes, who work closely with sports physi­cians, re­sults in a rush for the lat­est treat­ments, even be­fore the hard ev­i­dence is in.

The dis­cus­sion on whether so-called placebo prod­ucts should be used to im­prove per­for­mance re­quires on­go­ing di­a­logue. On the one hand, elite coaches ar­gue that any treat­ment that pro­vides a per­for­mance edge — even if un­proven phys­i­o­log­i­cally — is worth try­ing. On the other hand, many of these ther­a­pies come with risks, and sci­en­tists, coaches and med­i­cal ad­vis­ers must think hard about their mo­tives and jus­ti­fi­ca­tions. Is spec­u­la­tive med­i­cal ex­per­i­men­ta­tion re­ally good for sport? The his­tory of cy­cling would sug­gest not.

Bone grafts can speed up col­lar­bone heal­ing

Stem cell ther­apy for in­juries is as yet un­proven

Cup­ping’s ef­fects con­tra­dict its own premises

PRP has had mixed re­sults but is now WADA ap­proved

Acupunc­ture is pop­u­lar but the sci­ence is thin

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