To say Robin Clarke of Ellsworth has an active lifestyle is an understatement. She works as fitness director at the Down East Family YMCA in Ellsworth, where she can be found teaching Zumba and other classes, doing personal training and supporting members working toward health and fitness goals.
Off the clock, she’s a member of the large, active and fun-loving Hancock County running community. There’s a benefit or themed road race nearly every weekend, and Clarke can usually be found at the starting line.
She runs on vacation in Aruba, she said, where she has placed in 5K and 10K races and half marathons. Last year, she ran a half marathon in Puerto Rico.
One of the four full marathons under her belt is the New Orleans Rock and Roll Marathon, where she recorded a time that qualified her for the Boston Marathon.
Clarke ran Boston in 2015.
“This was one of the most memorable experiences of my life,” she said. “I was lucky enough to re-qualify this year for Boston 2016, running a time of 3:37:15.”
When a nagging pain in her right knee showed up this summer, she was not about to let it slow her down.
“I have many different aches, strains and pains, so I tend to wait it out, but this one didn’t go away,” she said. “My knee hurt for probably four months before I had it checked out.”
She had X-rays and an MRI done at Frenchman Bay Orthopedics at Maine Coast Memorial Hospital (MCMH) and was diagnosed with a meniscus tear.
Arthroscopic surgery was an option but would have meant no Boston 2016.
“I was literally on the way out the door when I asked about unconventional options,” she said. She learned that platelet-rich plasma (PRP) injections have helped some patients in her situation without surgery, but also that MCMH “didn’t have a price or a protocol” for the procedure.
Then, she discovered that Dr. Mark Kandutsch at Cadillac Family Practice in Bar Harbor has been doing PRP injections for several years. He also has worked to make them affordable since it’s usually not covered by insurance.
“I chose PRP to get me on the quick road to recovery to begin a 20-week training for April 18, Boston,” she said.
PRP injections were developed as an outgrowth of prolotherapy, which is another regenerative injection therapy that has been standard in orthopedic medicine for 25 years. Prolotherapy treatments include injection of dextrose and anesthetic into ligaments and are often used to treat back pain, according to Kandutsch.
“With PRP,” he said, “What you’re doing is you put the blood platelets into joint [or ligament, or tendon or whatever you’re trying to work on]. Platelets are normally thought of as the cells that produce blood clots. But they also contain tissue growth factors, which makes sense when you consider that they are activated in wounds.”
These growth factors are not considered hormones, strictly speaking, because they only act locally. The biochemical action is similar, though: some cells release signaling substances that affect other cells in the vicinity.
“PRP is good for people who are athletes and have maybe a meniscus problem but really don’t want to have the meniscus removed,” he said. “A high number of meniscus cases need surgery, but if it’s wear and tear-type damage, PRP can work for that. It also works for things like Achilles tendinitis, or plantar fasciitis damage in the foot.”
The process is very simple and can happen all in one visit, though a separate consultation ahead of time is common. Blood is drawn from the patient and spun in a centrifuge for 15 minutes to isolate the plasma. The area around the injection site it numbed, then the ultrasound-guided injection is administered to the affected joint or tendon.
The treatment is often painful, as is any so-called regenerative injection, Kandutsch said. “It works by using part of the inflammatory system in the body. So it’s necessary to have a certain amount of inflammation as part of the healing process.”
That means patients’ pain management shouldn’t include anti-inflammatory medicine such as Advil or Aleve. Other pain medication such as codeine may be prescribed or ice packs may help.
“I had read that the PRP was painful, so I was prepared,” Clarke said. “I was OK without taking anti-inflammatory drugs and used Tylenol instead as needed.”
Kandutsch calls PRP injections “somewhere between alternative medicine and a standard therapy,” because researchers haven’t been able to prove its effectiveness with before-and-after imaging techniques.
As a result, he said, no health insurance companies cover the procedure, except in some workers compensation or personal injury situations.
“When you make a claim about a therapy there has to be some evidence,” Kandutsch explained. “There’s really good evidence of healing for a lot of these ligament problems (plantar fasciitis, tennis elbow) because you can look at it with an ultrasound machine and actually see that the thing returned to a normal appearance and also the person’s symptoms go away.”
But when PRP injections are used to treat osteoarthritis, or a knee issue like Clarke’s, he said, “we don’t have an actual visualization of the healing because that would require MRI. And it would not be justifiable to order a $2,000 test just to see if something looks better.”
Kandutsch pointed to a small study done in Argentina where a group of people suffering from arthritis had arthroscopic images taken (cameras physically inserted into a small incision) before and nine months after PRP treatment.
“I’ve seen those images and you can see a huge difference in the cartilage,” he said, “but it wasn’t a very big study, so you can’t quote that as proof that it works.”
For his part, though, he has been pleased with his patients’ results from the treatment in the eight years that he’s been offering it.
“We always say when it comes to major joints like the knee or the hip that we are relying on patient symptoms and functionality rather than imaging proof,” Kandutsch said. “We’ve seen many patients get symptomatic and functional improvement so they can do their sport again or go back to work as a builder or mason. My guess is at least 80 percent get some kind of improvement.”
For athletes like Clarke, Kandutsch said, PRP can provide a boost to “remodeling” or repair processes already at work in the body. Remodeling takes place slowly in tissues such as a meniscus, or in highly loaded tendons like the Achilles, he said, because those tissues are mostly structural and don’t have a lot of active cells.
“If the wear and tear gets ahead of the remodeling then you get a chronic injury. Sometimes when you do a PRP treatment, it’s like you fire up the remodeling process, and then that gets ahead of the wear and tear and heals it.”
Following the short procedure in November, Clarke says, she stayed home on bed rest not bending her knee for 48 hours. But then she was right back up, “walking and bending a little more each day,” she said. Her knee seemed to have improved.
“The following Monday, exactly seven days after the injection, I went to work, personal trained, ran a mile with a client and taught an hour Zumba class that night. I ran a 5K, 10 days after PRP, and won it.”
She continues to train and can’t wait for Boston.