Platelet Regenerative Injection Therapy (PRP)
Prolotherapy is effective in healing weak and injured tissue primarily by inducing production of growth and repair factors. There is scientific evidence to support the concept that if the concentration of growth factors is increased 4 to 8 times the usual amount produced in an injury the healing of that injury is more rapid and effective. Therefore, it follows that it would benefit a patient if growth factors could be concentrated and delivered to an area that the body is trying to repair. That is, in fact, what Dr. Kochan has seen in the clinic and what has been observed in the few well done clinical trials that have thus far been conducted using concentrated platelet solutions as the source for these growth and repair factors.
Platelets aggregate at the sites of trauma and help to stop bleeding by assisting in clotting. They are also repositories of growth factors. After helping to stop the bleeding of an injury platelets release their growth factors into the area to initiate the healing process. In addition, white blood cells which migrate to sites of injury to help “clean up the mess” also contain significant amounts of growth factors which they add to the mix.
In the past, some physicians have injected autologous (the patient’s own) whole blood to the site of an injury, tissue weakness, degeneration, or pain to initiate and/ or accelerate healing of the tissue. This use of autologous blood has a long history but few published studies. Most of these studies investigated the injection of whole blood for patching leaking dural (spinal) punctures. More recently a few studies have looked at the injection of whole blood for musculo-ligamentous problems including for elbow tendinopathies (tennis elbow). The therapeutic components of whole blood which help healing are the platelets and white blood cells both of which contain growth factors.
Several companies have found cost effective ways to concentrate and isolate platelets and white blood cells using specialized centrifugation equipment. Until 2007, the primary uses of this autologous platelet rich plasma (PRP) had been to improve healing of sternal incisions and decrease incidence of infections after thoracotomy in cardiac surgery and in oral, maxillofacial and plastic surgery to prevent bone loss and promote bone formation and wound healing in conjunction with implants and oral reconstructive surgery. More recently, its use has expanded to include healing of skin ulcers with platelet gels, and in sports and musculoskeletal medicine.
The platelet/ white blood cell concentrations can be made to contain between four and eight times the baseline level of growth factors of whole blood depending on the needs of the patient as determined by the doctor. This platelet/ WBC concentrate contains many different growth factors, among them PDGF, IGF-1, TGF-1beta, EGF, and VEGF. It also has the ability to attract mesenchymal stem cells to regenerate many types of tissue. The few well designed sports medicine studies using PRP have been very positive. In one small study, nearly all symptoms of plantar fasciosis resolved within 4-8 weeks and ultrasound visualization showed increases in tissue integrity and organization. Rotator cuff tears showed marked reduction of symptoms and tissue healing after a single treatment. Elbow tendinopathies (medial and lateral) have responded to a single treatment in two different studies with significant relief of symptoms.
Dr. Kochan has had significant success treating knee arthritis with a combination of prolotherapy and PRP. Patients have had relief of pain and return of function including the ability to walk and climb stairs and in some cases even returning to running and playing tennis.
It is Dr. Kochan’s feeling that, except in rare cases, injection of PRP should not be used as stand alone treatment. Because the indications for using PRP are very similar to those for doing prolotherapy some physicians are using a single treatment with platelet rich plasma as a substitute for prolotherapy. However, Dr. Kochan feels that generally it needs to be done in conjunction with or even preceded by prolotherapy treatment.
Because the quantity of PRP obtained from a single blood draw is limited to only a few milliliters it is used to treat the structure or structures that are primarily responsible for the pain and/or dysfunction. Prolotherapy is then used to strengthen the secondary support structures. The ligaments, fascia and tendons around an injured joint, tendon, ligament or muscle work to support it and protect it from over strain, further injury and guide its motion and normal function. In an acute injury it is common that the structures in the area and sometimes in other areas are also injured. Thus, the supporting structures around a joint or injured ligament need to be evaluated and strengthened if necessary. If this is not done, the underlying instability and weakness of the supporting tissues will eventually cause the repair to fail and the problem will recur.
There are few negative aspects of PRP. The pain after treatment can be significant for periods of time of up to a couple of weeks. It is generally controlled well with ice and acetaminophen but sometimes will require stronger analgesics. Another draw back is the cost which is not insignificant and not often covered by insurance (so what’s new?) However, PRP injection treatment may decrease the number of prolotherapy treatments necessary and possibly shorten the time course of healing. It may be the only available alternative to a painful and costly surgery from which there is a long recovery even if it works well. Thus, in the long run it may be less expensive and less disabling than surgery and often is successful in improving function and decreasing pain in problems or in situations where surgery is not even an option. This is something that can and should be discussed on a case by case basis with Dr. Kochan.