Readers' comments following the previous article on Luka Modric which explained the theory and background behind the Croatian midfielder's recent Platelet-rich Plasma / stem cell treatment in Vitoria under the care of Dr Mikel Sanchez threw up some very interesting points. Discussion centred on both the legality of the procedures used and also touched on ethical issues. Comments also highlighted the current stance against performance enhancing substances in sport and the potential for random drug testing.
With the current emphasis placed on the detection of players / athletes using illegal and illegal substances by both the World Anti-Doping Agency (WADA) and the football authorities themselves, it is vital to ensure that all procedures undertaken and any substances given are legal and well-above board. Random testing can be held at any time at any club without notice being required in advance as described in a previous article, so everyone in football needs to be aware of what is allowed and what is not. In doing so, the responsibility in practical terms falls between both club and player, but ultimately in legal terms the responsibility falls to the players or athletes themselves to ensure that whatever substances they are taking (or procedures they are undergoing as in Luka's case) do not contravene current WADA legislation.
This is not as difficult as it sounds. WADA have an easily-found website which enables players to contact them directly and take advice on the legality of any substances and / or procedures. It is a very simple process for a player just to pick up the phone and ask if a substance is legal or if a particular procedure is banned or allowed. However, although the responsibility for making players aware that this facility exists is usually gladly accepted by the clubs, in practice it is the club physiotherapists and doctors who generally take the responsibility for player education. It falls on the medical staff to ensure that players appreciate the importance of checking the legality of whatever supplements they may be taking, and provide guidance on how to ensure that any substances used do not appear on the prohibited list. This applies to surgical procedures in addition to medication and vitamin / mineral supplementation.
Platelet-rich Plasma (PRP) as a treatment is not prohibited in sport. PRP has been approved by WADA as a perfectly legal and recognised form of medical treatment provided that the procedure is carried out by a registered medical doctor. The problem can be when PRP and stem cells are then mixed with Human Growth Hormone (HGH) to enhance the procedure since this is known to accelerate healing but is in direct contravention of doping regulations. This happens when another and less common form of stem cell therapy is used; a procedure which on it's own is once again perfectly legal but is more applicable to injuries and conditions affecting the bone surfaces as opposed to soft-tissue muscle, tendon or ligamentous structures. This particular application is used to treat conditions such as degenerative and age-related joint changes that directly affect the bones, together with some arthritic conditions. It is with certain stem cell treatments in this category that the issue arises when Human Growth Hormone is added to the mixture. This makes it a prohibited procedure for athletes.
In 2010, WADA did actually ban the straight-forward treatment using PRP alone; but this was repealed in 2011 and PRP was removed from the prohibited list. It was felt that, despite the presence of some growth factors in the process, these were natural and did "not demonstrate any potential for performance enhancement beyond a potential therapeutic effect". Additionally, with the procedure being autologous, i.e. with the plasma coming from the same patient that the serum is intended for, unless additives are introduced (such as growth hormone) the amount of stimulus derived was considered just enough to enhance the healing process but not enough to have a performance-enhancing effect.
Studies around that time appeared to indicate that the natural growth hormones found in the treatment serum were not present in significant enough amounts to provide a potential stimulatory effect in a performance-enhancing sense. WADA subsequently found in favour of the treatment as a recognised form of therapy with a foundation in science, and as a result the procedure was finally removed from the prohibited list.
It appears that the key word in those last two paragraphs is "potential". There has been a considerable amount of research over the past few years into the effects of PRP / stem cell infiltration and results have generally been encouraging. Like most treatments of this kind, however, it is difficult to say with 100% certainty how effective the procedure is in terms of enhanced recovery. It is hoped that since this treatment is not exclusive to sportspeople alone, a fair representation of the results have been spread across the board and a fair conclusion can be drawn as to it's likely success or failure. Some of the research has been undertaken by Mikel Sanchez in Vitoria and positive results have been reported. Certainly people like Rafa Nadal are not going to keep going back to Pais Vasco for a treatment that doesn't work for them, and if the therapy helps to get Luka Modric back on the field quicker then the whole procedure will have been well worthwhile.
Ethical questions concern whether the procedure gives a recipient an unfair advantage or not. In this case, the treatment is theoretically available to all therefore in theory at least the procedure is open to everyone. However, it could be argued with some justification that although PRP /stem cell treatment is available to all, the procedure is not necessarily accessible to all. So does this constitute an unfair advantage to those clubs and players who can readily access it over those who may not be able to? If this is perceived to be the case, then at what point do we draw the hypothetical line in the sand? Do we also then consider Real Madrid having immediate access to first-class medical facilities to constitute an unfair advantage over other teams?
PRP / stem cell treatment should not be categorised alongside other alternative treatments referred to in the previous article. Injecting calves' blood into muscle tissue for example is classed as homeopathic medicine and Hans Muller-Wohlfahrt in Munich is completely open about this. There is a growing trend towards alternative and homeopathic medicines nowadays for injury treatment, and at one stage vitamin injections were all the rage for muscle strains. These injections were thought to stimulate the healing process in much the same way as the current treatment used by Luka Modric is thought to; by introducing natural substances at higher volumes and concentrating these on the affected areas.
Provided that HGH is not used then the procedure is legal as applicable to sportspeople; and the general opinion is that Luka's treatment is safe and potentially effective. Studies are continuing at present into the concentration of the serum to determine how much the natural growth factors associated with this form of treatment have an influence on recovery; and secondly to identify the actual volume of growth factors present in the serum injected. In terms of recovery for Luka Modric, though, only time will tell. As mentioned in the previous article, although the signs are positive sometimes the easy bit is just letting the doctor do his work. The hardest part often comes when the running and the real fitness work begin.
For sure, the presence of Luka Modric has been missed in the Madrid midfield for a long time and the news that he is now working at a decent level is encouraging. Let's all hope the recovery continues and things go to plan. His latest targeted comeback match was stated in Marca a few days ago as being the Champions League match against Schalke 04 on the 19th February. That's only three weeks away so there's a lot of work to be done between now and then.