Platelet-Rich Plasma (PRP) Injections and their Effectiveness
In the past few years, a lot has been written about platelet-rich plasma (PRP) preparation and how it can accelerate the healing of wounds and injuries. Activation of platelet plays a very important role in the process of soft tissue and wound healing.
In the past, several popular athletes including Rafael Nadal and Tiger Woods have undergone PRP for many different types of problems, like chronic tendon injuries and sprained ankles. These conditions are generally treated with physical therapy, medications, and even surgeries. Many of these athletes have suggested that it was thanks to PRP that they were able to quickly return to competing at maximum performance.
While a lot has been said in favour of Platelet-rich plasma, there are still several questions which linger, like:
- What exactly is PRP?
- How does PRP work?
- Is PRP effective?
- Is PRP safe?
This post will try to answer all of these common questions in a simple and effective manner.
What is Platelet-Rich Plasma?
While the human blood is mostly liquid (plasma), it also contains several other components in very small quantities (white and red blood cells, platelets). Platelets the the part of blood which stop us from bleeding when we injure ourselves. For example if you do not have an optimal concentration of platelets circulating in your system and you cut yourself it will take a very long time for the bleeding to stop. You will also bruise very easily. Platelets not only stop the bleeding but they initiate the entire healing cascade. Once the platelets have stopped the bleeding at your cut they release a large number of various types of growth factors which immediately begin the healing process until in a few days your cut has healed and you can not see where it was.
Platelet-rich plasma is plasma which has concentrated the platelets into a very small volume. Thus after drawing 60 mls of blood from a patient we may only have 2-3 mls of PRP at the end depending on the health of the patient. In platelet-rich plasma, the platelet (growth factor) concentration can rise many times, often as a factor as low as 5 times all the way through to 22 times increased concentration depending on which extracting machine and technique is used.
To obtain platelet-rich plasma an amount of blood is drawn from the patient. Once the blood is drawn, it is then processed and extracted in our state of the art Arthrex Angel system. This entirely closed system (meaning your blood is never exposed to the external environment ultimately decreasing any risk of infection.) separates the platelets and releases the PRP into a sterile syringe.
How do Platelets Help in Healing?
Platelets act as a reservoir of growth factors, which play a very important role in the healing process. After an injury, the endogenous inflammatory response results in activation of platelets and starts delivering many different types of growth factors to the injured area. Some of the most important growth factors in the process include:
|Growth Factor||Effects on Tissue Repair|
|TFG-β (Transforming Growth Factor-Beta)||Stimulates the proliferation of fibroblast, forms collagen and components of extracellular matrix|
|PDGF (Platelet-Derived Growth Factor)||Encourages proliferation of fibroblast, enhances synthesis of collagen|
|EGF (Epidermal Growth Factor)||Stimulates proliferation of cells|
|IGF (Insulin-like Growth Factor)||Helps in repair and growth of the skeletal muscle|
|VEGF (Vascular Endothelial Growth Factor)||Promotes angiogenesis|
Application of prp
A number of laboratory studies have confirmed that increasing growth factor concentration can significantly accelerate the healing process.
Platelet-rich plasma is generally injected directly into the injury site. For instance, if the patient is suffering from Achilles tendonitis, which is a condition commonly observed in tennis players and runners where the tendon becomes painful, swollen, and inflamed, a local anesthetic along with platelet-rich plasma is injected directly into the inflamed tissue under ultrasound guidance.
Administration of PRP
The preparation and administration of platelet-rich plasma is done in many different ways. Most Doctors make use of special kits which can be used for the separation of PRP from normal blood, along with centrifugation and anticoagulants. On the other hand, many simply centrifuge the blood with anticoagulants and then manually collect the platelet-rich plasma after centrifugation.
Currently, there is no evidence which suggests that one single method can help in yielding better PRP when compared to another method. However, I use only the Arthrex Angel, a system which is entirely closed, meaning there is significantly reduced chance for any pathogen to enter into your plasma. From the moment the blood is drawn from the patient, spun, extracted and injected back into the patient, it is never exposed to the external environment. This is of paramount importance.
Though there are many different methods used for preparing PRP ultimately it is the concentration of the platelets which matters most. Research suggests that the platelet concentration must be at least 4 to 6 times for it to be effective.
Precision Requirements of PRP
It is highly recommended that only experienced physicians administer platelet-rich plasma injections. Some of the physicians in Halifax, such as myself, also use imaging technology. Ultrasound guidance provides enhanced precision and ensures that the platelet-rich plasma is injected exactly where it is required.
Precision plays a very important role when administering platelet-rich plasma injections, and just like viscosupplementation treatments, the injection should be directly injected to the joint capsule.
Platelet-rich Plasma Precautions
As per the American Academy of Orthopaedic Surgeons, PRP patients should adhere to the precautions mentioned below:
- Corticosteroid medications should be avoided at least 2-3 weeks before the platelet-rich plasma procedure
- Anticoagulation medication should be avoided at least 5 days before the platelet-rich plasma procedure
- Non-steroidal anti-inflammatory drugs (NSAIDs), like ibuprofen or aspirin or medications for arthritis should also be avoided at least 1 week before the PRP procedure
- Make sure that you drink a lot of fluids the day before the platelet-rich plasma procedure
- Some of the patients might also require anti-anxiety medication just before the procedure
While the American Academy of Orthopaedic Surgeons has published these guidelines, the organization is not against, nor does it advocate for, PRP treatments.
After a platelet-rich plasma procedure I advise patients to rest and try to limit activity to only what is required for activities of daily living.
Other suggestions can include:
- Avoid taking any kind of anti-inflammatory pain medication; physician might prescribe some other pain medication
- Ice packs can be applied to the injection site to reduce swelling and irritation.
If you have a sedentary office job you can return to work immediately. If you have a highly active job I recommend a minimum of 2-3 days off work or returning to work on reduced duties.
PRP versus Corticosteroid Injections
One of the most common questions I am asked by patients is what are my options other than cortisone injections? I always run through the various treatment options. Acupuncture, massage therapy, physio, proper nutrition etc… However, a study released just a month ago was conducted specifically on knee arthritis, both stage 3 and 4 (stage 4 is your most advanced stage of arthritis). This study compared the effectiveness of a single platelet rich plasma (PRP) injection to that of a steroid cortisone injection. It found that a single PRP injection improved activities of daily living and quality of life in patients with advanced osteoarthritis. Specifically in patients aged 67 years or older it found that a single PRP injection yielded similar results to that of a single cortisone injections.
Effectiveness of PRP
Several studies in the recent past suggest that PRP injections are indeed very effective when it comes to accelerating the healing process of injuries, while others have suggested that more research is required.
Here are some of the most recent studies on PRP from 2016 through to June 2017.
Safety of PRP
As PRP is prepared directly from the blood of the patient there are no chances of developing any transmittable diseases if adequate sterile techniques are followed which is why we only use an entirely closed system (Arthrex Angel). Negative effects of PRP injections are very rare, however carry the same side effects as other injections. these side effects can include bruising at the site of injection, soreness and increased pain for a period of time.
The use of platelet-rich plasma injections in the field of orthopaedics is still very new, and the first study was only published just a few years ago. However, in such a short span of time several review papers and clinical trials have already been published on the topic. There are several conditions, such as lateral epicondylitis, which have achieved positive results when treated with platelet-rich plasma injections.
Moreover, many of the studies have also concluded that PRP injections provide better results when compared to other treatments, like corticosteroid injections. Even the adverse effects of PRP injections are minimal as compared to the adverse effects of corticosteroid injections.
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Platelet-rich Plasma Therapy is now available in Halifax
For more information on platelet-rich plasma check out our info on Cornerstone Naturopathic. A leading Naturopathic clinic in Halifax.
Yadav R, Kothari SY, Borah D. Comparison of Local Injection of Platelet Rich Plasma and Corticosteroids in the Treatment of Lateral Epicondylitis of Humerus. J Clin Diagn Res. 2015;9(7):RC05-RC07.
Sandeep Patel,MS, Mandeep S. Dhillon, MS, FAMS, Sameer Aggarwal,*, Neelam Marwaha, MD, FAMS, and Ashish Jain, MD. Investigation performed at the Department of Orthopaedics and Department of Transfusion Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Rodriguez JA. Corticosteroid versus platelet-rich plasma injection in epicondylitis. Orthop Nurs. 2014;33(5):257-265.
Thompson C, Visco C. Lateral epicondylosis: emerging management options. Curr Sports Med Rep. 2015;14(3):215-220.
Kahlenberg CA, Knesek M, Terry MA. New Developments in the Use of Biologics and Other Modalities in the Management of Lateral Epicondylitis. Biomed Res Int. 2015;2015:439309.
de Vos RJ, Windt J, Weir A. Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. Br J Sports Med. 2014;48(12):952-956.