Platelet Rich Plasma
What is Platelet Rich Plasma? How is it Used?
The use of platelets in the treatment of injuries has been available for over 30 years. In more recent years, high profile athletes have brought its benefits to recovery and quick return to sport to the forefront. Now Platelet Rich Plasma (PRP) is considered a first-line treatment to muscle, fascial, ligament or joint injuries that cause pain and/or dysfunction.
Platelet Rich Plasma is derived from blood. A centrifuge is used to remove red blood cells, white blood cells and most of the plasma, the yellow liquid form of blood. Platelets are then concentrated by a second centrifuge, and are re-suspended in the plasma. Hence the name, Platelet Rich Plasma.
Platelets are produced in the bone marrow. Within the platelets are clotting factors, growth factors, honing molecules and other proteins that regulate healing. Platelets, which live for 7-10 days, stop bleeding, initiate healing, and encourage a new blood supply.
Healing occurs in 3 distinct phases:
The first is an inflammatory phase, which begins when platelets are drawn to a site and become activated, releasing the growth factors necessary for healing. This phase lasts 3-5 days, and is an important time to avoid anti-inflammatories (such as Ibuprofen, Naprosyn, Diclofenac, Aleve), as inflammation promotes healing.
The second phase, the proliferative phase, occurs over a period of weeks. During this time, cellular material forms in a layered approach, and new blood vessels form. The layers of differentiated cells form a matrix that strengthens the injured tissue. This is the phase of healing when tissues are most prone to re-injury. It is important to moderate activity to avoid re-injury during this time.
The third phase of healing is called the remodeling phase. This lasts up to a year. During this period, collagen continues to develop and gets deposited in layers, adding strength to the tissue.
Each of the 3 stages are necessary for full healing. Interruption of any part of healing by a second injury, or by the use of anti-inflammatories, can cause incomplete healing, leading to chronic injuries (defined by an injury that lasts 6 or more weeks).
Chronic injury to the supporting ligaments of a joint can lead to arthritis. Chronic injury to a tendon leads to tendinopathy. In both situations, the tissue quality is compromised, as is blood supply, further detracting from healing.
PRP is used to treat injured ligaments, tendons, and capsules around a joint to improve joint stability and improve healing in, for example, knee and hip arthritis, as well as back pain and most other joint pain. Injuries to ligaments, tendons and capsules cause about 60% of the pain people experience around their knees. It is important to understand that prior to pursuing surgical treatment, as not all pain will be resolved by surgery and sometimes treatment of these ares prior to surgery can improved the success of the surgery.
PRP can also be injected into joints to assist with repair of the articular cartilage and meniscus. The addition of bone marrow and or fat stem cells may be important in these situations to augment healing, depending on the degree of damage.
The injection of PRP is done under direct visualization, such as ultrasound or fluoroscopy, to guide the needle into the specific area that was injured. The skin and deeper middle tissue are numbed prior to injecting PRP, which lessens – but does not fully eliminate the discomfort.
The risk of treatment with PRP includes allergy to the anesthetic and injury or puncture of a deeper structure or nerve. Both can be avoided by the interview process, and with skilled use of ultrasound. Bruising to the injected area can be expected . There is a low risk of infection.
PRP is the second tier to regenerative procedures. The first is prolotherapy, and the third is stem cell treatment. The decision to use one therapy over another is determined by the degree of injury and other health conditions.
Bracing, orthodics, or taping may be needed to augment healing in the correct anatomical position.
Supplements and hormonal balance therapies may also assist with healing. Physical Therapy is often paramount to full recovery.
How does PRP injections compare to prolotherapy?
Many of the same principles apply. See prolotherapy FAQs. PRP is not comfortable and requires anesthesia. Nerve blocks and local anesthesia are done to give local relief. Because PRP is viscous and there are other pain pathways, besides nerve pain, there continues to be some injection discomfort. Injecting PRP slowly improves pain tolerance. In certain patients, oral medications can be used to assist with pain. Nitrous oxide is available in some offices. In addition, we welcome having patients bring in their own music. Tapping, meditation and other techniques are helpful. That being said, the benefit is significant. See above testimonials. The pain compared to having joint replacement is days, not weeks.
What should be expected post procedure?
The inflammatory response is greater with PRP, so 3-5 days of increased swelling with or without pain is normal. Some people have little to no swelling or pain after 24 hours and others have more. Use of crutches for 1-3 days to avoid weight bearing is suggested for treatment of the lower body. Sling for the upper body is helpful. Compression of the joint is helpful. Avoidance of heat during the first 24 hours helps reduce the inflammation that would be increased as blood vessels dilate. Ice slows down the inflammation, which is used at times with people who experience a lot of discomfort.
When would Physical Therapy start?
Typically, PT is started at the earliest 2 weeks after the last PRP session. Care is taken to prevent injury from being “pushed” too fast or too early… before healing has occurred fully. For this reason, some doctors who treat patients with regenerative injections, will not send their patients to PT until after the treatment is done.
Is there any safe exercise?
Aerobic exercise in the form of elliptical machine or stationary bike or swimming can be continued depending on the injured area.
Stabilization exercise, such as pilates, gyrotonics and some forms of yoga work well. We want to keep the tissue pliable, but not overstretched, which can happen if you aren’t careful while doing yoga.
Avoid strength training until you have painless full range of motion and have built up some of the stabilizer or core muscles of the joint. Resistive bands are a good way to build up stabilization of a joint, start with yellow bands and progress thru the rainbow. Exercises using your body weight as the resistance is a further progression of stabilization into strength exercises. Typically the earliest strength training would occur at 6 wks to 2 months.