PLATELET RICH PLASMA PRP
WHAT IS PLATELET-RICH PLASMA PRP?
Almost a decade ago, doctors at the University of Rochester wrote: ” Platelet-rich plasma (PRP) is an orthobiologic that has recently gained popularity as an adjuvant treatment for musculoskeletal injuries. It is a volume of fractionated plasma from the patient’s own blood that contains platelet concentrate. The platelets contain alpha granules that are rich in several growth factors . . .which play key roles in tissue repair mechanisms. PRP has found application in diverse surgical fields to enhance bone and soft-tissue healing by placing supra-physiological concentrations of autologous platelets at the site of tissue damage. The relative ease of preparation, applicability in the clinical setting, favorable safety profile and possible beneficial outcome make PRP a promising therapeutic approach for future regenerative treatments.”(1) There has been a lot of new research since.
PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. PRP puts specific components in the blood to work. Blood is made up of four main components; plasma, red blood cells, white blood cells, and platelets. Each part plays a role in keeping your body functioning properly. Platelets act as wound and injury healers. They are first on the scene at an injury, clotting to stop any bleeding and immediately helping to regenerate new tissue in the wounded area.
The platelets contain healing agents, or “growth factors.” Let’s look at some of the growth factors and what they do:
- Platelet-derived growth factor (PDGF) is a protein that helps control cell growth and division, especially blood vessels. When more blood (and the oxygen it carries) is delivered to the site of a wound, there is more healing.
- Transforming growth factor beta (or TGF-β) is a polypeptide and is important in tissue regeneration.
- Insulin-like growth factors are signaling agents. They help change the environment of the damaged joint from diseased to healing by “signaling” the immune system to start rebuilding tissue.
- Vascular endothelial growth factor (VEGF) is an important protein that brings healing oxygen to damaged tissue where blood circulation might be damaged or inadequate.
- Epidermal growth factor plays a key role in tissue repair mechanisms.
PRP FOR BONE HEALING AND REGENERATION
Researchers at the University of Memphis and Saint Louis University acknowledge that there is little doubt that the growth factor milieu contained within PRP has the potential to be highly beneficial to bone regeneration.(2) In fact, PRP is such a promising treatment for bone regeneration that doctors also support the use of PRP for large bone defects to assist healing and bone regeneration.(3) Researchers have confirmed that PRP accelerates the healing and growth of bone in large-bone tumor-created defects and other defects.(4),(5) It is also being studied for routine use in regeneration of cystic bony defects (characteristics of bone tumors) in children.(6)
Hip Osteoarthritis
For more research please see my article: PRP injections to treat Hip Osteoarthritis
- Researchers at the University of Florence found that the majority of patients receiving PRP for hip osteoarthritis had significant pain reduction at 6-7 weeks that was sustained at 6 months, and they also had better range of motion.(7)
- More Italian research from the Rizzoli Orthopedic Institute showed improved findings: “Results indicated that intra-articular PRP injections offer a significant clinical improvement in patients with hip osteoarthritis without relevant side effects.”(8)
- Even after hip surgery, researchers in Chile noted that PRP was effective in reducing pain that continued after the surgery.(9)
- In 2018 a study (10) from the United Kingdom suggested: “Literature to date concludes that intra-articular platelet-rich plasma injections of the hip, performed under ultrasound guidance to treat hip osteoarthritis, are well tolerated and potentially efficacious in delivering long-term and clinically significant pain reduction and functional improvement in patients with hip osteoarthritis.”
Hip osteoarthritis is treated almost daily in my office. The most amazing recovery is that of a man who was a life-long body builder. His left hip was almost fused, with no range of motion. I refused to treat the hip since I didn’t think PRP would help. Instead I used PRP on his right knee. After some success with his knee he begged me to inject his hip. I finally did, and to my surprise, he was then able to reach down to the floor to pick up weights. A movement he could not do for years before. This of course is not typical of every patient. It is his story.
Degenerative Disc Disease
In 2019 we published our study on the effectiveness of PRP treatments for the patient for chronic low back pain. The study appears in the journal Cogent Medicine.(11)
This research gives an insight into what level of treatment success we can have with certain back pain conditions and how many PRP treatments the patient should expect towards achieving their treatment goals. In this study, we demonstrated PRP outcomes in 67 of our patients.
Methods:
- 67 patients underwent a series one, two, or three PRP injections into the ligaments, muscle, and fascia surrounding the lumbar spine.
- Patients who received two treatments received injections a mean 24 days apart and patients who received three treatments received injections a mean 20.5 days apart.
- Baseline and post-treatment outcomes of resting pain, active pain, lower functionality scale, and overall improvement percentage were compared to baseline and between groups.
Results:
- Patients who received one PRP injection reported 36.33% overall improvement and experienced significant improvements in active pain relief. These same patients experienced improvements in resting pain and functionality score, yet these results were not statistically significant.
- Patients who received a series of two and three treatments experienced significant decreases in resting pain and active pain and reported 46.17% and 54.91% total overall improvement respectively. In addition, they were able to perform daily activities with less difficulty than prior to treatment.
The learning points of our study: Patients returning to everyday activities, Patients reporting immediate clinical benefit
Our results demonstrated that PRP injections may be a viable conservative approach to treat lower back pain in regards to getting patients back to their everyday activities and improving pain and function.
- Patients quickly returning to everyday activities:
- Our study demonstrated that one, two or three PRP treatments were effective in significantly reducing active pain in the lower back. Additionally, functionality scores were significantly increased showing that patients were able to quickly return to everyday activities.
- An immediate clinical benefit:
- Patients experienced an improvement in resting pain and functionality score after the one treatment, however, statistical significance was demonstrated only after the second and third treatments. Yet, self-reported mean total improvement was 36.33%, 46.17%, and 54.91% at the first, second and third treatments, respectively, suggesting an immediate clinical benefit.
There is much more information on low back pain and PRP at my article: Platelet rich plasma injections chronic low back pain.
- Patients who received one PRP injection reported 36.33% overall improvement and experienced significant improvements in active pain relief. These same patients experienced improvements in resting pain and functionality score, yet these results were not statistically significant.
- Patients who received a series of two and three treatments experienced significant decreases in resting pain and active pain and reported 46.17% and 54.91% total overall improvement respectively. In addition, they were able to perform daily activities with less difficulty than prior to treatment.
The learning points of our study: Patients returning to everyday activities, Patients reporting immediate clinical benefit
Our results demonstrated that PRP injections may be a viable conservative approach to treat lower back pain in regards to getting patients back to their everyday activities and improving pain and function.
- Patients quickly returning to everyday activities:
- Our study demonstrated that one, two or three PRP treatments were effective in significantly reducing active pain in the lower back. Additionally, functionality scores were significantly increased showing that patients were able to quickly return to everyday activities.
- An immediate clinical benefit:
- Patients experienced an improvement in resting pain and functionality score after the one treatment, however, statistical significance was demonstrated only after the second and third treatments. Yet, self-reported mean total improvement was 36.33%, 46.17%, and 54.91% at the first, second and third treatments, respectively, suggesting an immediate clinical benefit.
Knee Osteoarthritis
One study showed that “[I]ntra-knee articular injection of PRP to treat knee articular cartilage degeneration is safe, [and] can alleviate symptoms of pain and swelling and improve the quality of life of patients.”(12) Researchers in Barcelona, Spain were able to report results at six months showed improvements in patients’ knee function and quality of life.11
Another study from doctors in Thailand found that PRP produced greater improvement in knees than hyaluronic acid injection and placebos in terms of reducing symptoms and improving function, as well as in improving quality of life.12 In a study from the Mayo Clinic, PRP was seen to be more effective than hyaluronic acid in younger, active patients with low-grade osteoarthritis.13
PRP has demonstrated significant improvements in Knee Injury and Osteoarthritis Outcome Scores, including pain and symptom relief, in addition to having the ability to provide pain relief, halt progression of meniscal damage, and regenerate tissue.14,15
In supportive research in the surgical journal Arthroscopy, doctors concluded that PRP injections are a viable treatment for knee osteoarthritis and should be considered for patients with this condition.16
Studies like these add to the accumulating evidence that PRP can halt and reverse meniscus degeneration.17,18,19
The most common issue that I see in the office is knee OA. I inject PRP and stem cells into many knees every day. I use an ultrasound to guide the needle to make sure the solution enters the joint. Without ultrasound guidance, there is a 33% chance that the solution will actually miss the joint, and end up in the soft tissue. Not only will that not be a healing action, but it can cause a huge inflammatory reaction with an effusion (fluid in the knee). I have heard patients say that having a baby was easier.
Kneecap and Tendons
Patellar tendinopathy, often called “runner’s knee,” is a condition that has been shown to respond very favorably to Platelet-Rich Plasma Therapy. Researchers in the Netherlands reported: “After PRP treatment, patients with patellar tendinopathy showed a statistically significant and meaningful improvement.”20
Rotator Cuff- Shoulder
- Injections of PRP have led to reduced pain and improved recovery for the treatment of rotator cuff tears.21,22
- PRP also enhances rotator cuff repair following arthroscopic shoulder surgery.23
- At a meeting of the American Academy of Orthopaedic Surgeons, researchers suggested that PRP injections may be a safe and cost-effective treatment alternative for rotator cuff tendinopathy (RCT) .My experience is that it also works on full-thickness tears. I inject shoulders every day, and have seen patients who can’t lift their arm because of a tear, get pain free, complete range of motion.24
Tennis Elbow
Patients with chronic lateral epicondylitis, known as tennis elbow, received PRP injections once or twice at four-week intervals in a recent study, complemented with standardized physical therapy. Six months after the localized PRP treatment, these patients reported significant pain relief and gain in function, as well as improved quality of life. According to doctors at the Rizzoli Orthopedic Institute and University of Bologna in Italy, a single PRP injection may be sufficient.25 Doctors from the United Kingdom confirmed these findings, showing that PRP injections have an important and effective role in treatment of the elbow, especially in difficult cases of tennis elbow.26
Achilles Tendinopathies- Ankle/Foot
Patients with chronic lateral epicondylitis, known as tennis elbow, received PRP injections once or twice at four-week intervals in a recent study, complemented with standardized physical therapy. Six months after the localized PRP treatment, these patients reported significant pain relief and gain in function, as well as improved quality of life. According to doctors at the Rizzoli Orthopedic Institute and University of Bologna in Italy, a single PRP injection may be sufficient.25 Doctors from the United Kingdom confirmed these findings, showing that PRP injections have an important and effective role in treatment of the elbow, especially in difficult cases of tennis elbow.26
TMJ
- Doctors in Egypt studied 50 patients with TMJ-osteoarthritis. They found that PRP performed better than hyaluronic acid during long-term follow-up in terms of pain reduction and increased interincisal distance – that is, the ability to open one’s mouth wider.60 In a study done in Turkey, researchers concluded that patients suffering from temporomandibular joint (TMJ) disc dislocation benefited more from PRP injections than from surgery to manipulate the jaw back into place. Clearly, PRP stabilized the joint and reduced chronic instability.30
- A study in Poland found that platelet-rich plasma injections into the temporomandibular joint had a positive impact on the reduction of the intensity of pain experienced by patients who were being treated for TMJ dysfunction.31
References
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24. http://www.aaos.org/CustomTemplates/AcadNewsArticle.aspx?id=8767&ssopc=1
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