PLATELET RICH PLASMA THERAPY (PRP)

Platelet rich plasma therapy, or PRP, is likely the most well-known of the regenerative medicine modalities out there. It’s been featured on sports shows and TV medical shows like “The Doctors,” and there are no shortage of websites and YouTube videos dedicated to it. For an injured athlete, PRP can be his or her saving grace. I would venture to guess that there’s hardly a college or university in this country that does not have a physician who performs this amazing procedure for his or her athletes. It’s also quite likely that every professional sports team in this country and most others (NBA, NFL, MLB, FIFA soccer, etc.) have made extensive use of this career-saving elixir.

Here’s the list of joints that I’ve had injected with PRP (both by other physicians and self-administered): both knees, right hip, low back, and pelvis. PRP was a big reason why I can run today instead of only walking.

It’s why I can bend to a full squat and explosively jump as high as I want without feeling sharp, aching, grating pain in my knees and back that once kept me up at night. As I like to say, the best measuring stick for any procedure are results you can feel. I’m writing this book at the age of 48, and thanks in large part to PRP therapy, I’m able to jog, sprint, jump, stretch, and kick comfortably after a little warming up. Not bad for an old man.

For people who have severe, nagging injuries that show clinical and even imaging evidence of more advanced wear and tear, I’ll often recommend PRP as an option. Let’s talk a minute about where PRP came from and how it works, to see if this marvel of science might help you.

THE HISTORY OF PRP

The first preparations of PRP go back to the 1950s, but it wasn’t until the use of modern centrifuge techniques in the 1980s that a select group of physicians and dentists began using it for jaw reconstruction. The first published study on the subject came out in 1987, when Dr. M. Ferrari and colleagues used it as a transfusion after open heart surgery to minimize blood loss and prevent the need for blood transfusion. It quickly gained popularity with oral surgeons and veterinary medicine, particularly for treating musculoskeletal injuries in horses.

PRP began being used more frequently in the 1990s but didn’t gain significant attention until the early 21st century when its beneficial effects were noticed on sports injuries. Further studies were done by researchers, including Stanford University’s Dr. Alan Mishra on its benefit with conditions such as lateral epicondylitis (“tennis elbow”).2 The success of PRP became so prevalent that soon most professional sports teams were employing it for their athletes, given the success it showed in healing sports injuries and getting the players back in competition.

Despite these achievements, however, PRP remained largely an unknown treatment option until an opportunity came up on the national stage

to demonstrate its effectiveness. Super Bowl XLIII in 2009 featured the Pittsburgh Steelers vs. the Arizona Cardinals. Unfortunately for the Steelers, their best receiver, Hines Ward, suffered an injury to his medical collateral ligament (MCL) during the AFC championship game on January 18th with the big game only two weeks away. This type of injury takes several weeks to heal on its own, and the healing is often incomplete, so Ward’s status for the Super Bowl was doubtful at best. Hines elected to receive PRP treatment to his knee.

Results:

After a short rest period, he was cleared on game day to play with a brace on his knee. He went on to have a great game to help his team to Super Bowl victory! Other athletes, such as Major League pitcher Takashi Saito of the Los Angeles Dodgers and Ward’s teammate Troy Polamalu, have received PRP to great success. In Saito’s case it enabled him to avoid Tommy John surgery (replacing the damaged ulnar collateral ligament on the inside of the elbow with a tendon from a cadaver or from another part of the body), and Polamalu has stated that PRP was instrumental in prolonging his playing career.

HOW PRP WORKS

The good news is that if you’ve read this far, you already have a great understanding of the fundamental principle of regenerative medicine – that inflammation is paramount for tissue regeneration. If you’re being technical, both PRP and stem cell therapy are Prolotherapy as well, since “prolo” comes from the Latin root word meaning “to regenerate.” As a rule, we don’t call other forms of regenerative medicine “prolotherapy” to avoid confusion.

On to how PRP works. After a good history and exam are done to determine where the problem areas are, PRP begins with a blood draw, typically in the range of 50 to 150 milliliters (occasionally more). The syringe has anticoagulant added to avoid clotting. This blood is transferred into special containers that are placed into a centrifuge to spin the blood rapidly to separate out the blood components by layers. The container is removed, and the top layers of blood product containing the lightest elements in it—the plasma, or fluid component, and the platelets, which are present in a thin “buffy coat” layer just below the plasma—are then drawn out.

This Platelet Poor Plasma (PPP) is then put back into the centrifuge with a counterweight and spun again for several minutes. The remaining suspension is then calibrated for the specific amount of PRP the physician wants for the procedure and platelet concentration desired. This platelet-rich plasma can now be injected into the needed area(s) of the body.

After the first spin in the centrifuge, the layers of blood products are clearly visible. The top two layers—the platelet-poor and platelet-rich plasma—are collected to undergo a second spin, while the cell (lowest) layer is discarded.

After the second spin and removal of the excess platelet-poor plasma, the sterile tube is swirled to dislodge the platelets sticking to the bottom and disperse them into solution, which is then drawn up into a syringe for injection. Voilà, PRP!

PROLOTHERAPY VS. PRP

In simpler terms, think of PRP as traditional therapy, but instead of just “watering” the treatment area, it’s like adding fertilizer to the mix. In practical terms, I’ve found in my practice that PRP as a whole works at least as well, if not better, than Prolotherapy in most cases, and with fewer treatments necessary. Typically, one PRP injection carries the equivalent of three Prolotherapy injections. I repeat “typically,” as results can vary.

SOME EXAMPLES OF PRP OUTCOMES

CASE #1 – PRP FOR KNEE PAIN

Melanie was a middle-aged woman who for a year was suffering from severe left knee pain that had gotten acutely worse. Physical therapy had been helpful initially, but on a repeat visit to my office she stated that for the last 10 days she had been experiencing more pain, swelling, stiffness, and an inability to fully extend her leg. Her MRI matched my suspicion of a tear in her lateral meniscus (the shock absorbing cartilage semicircle on top of the tibia, or shin bone), as well as chondromalacia (literally, “softening of the cartilage” that occurs with knee degeneration). She also noted that she had developed pain in both her left heel and arch, and a pain in her left buttock that would radiate down her leg, both worse since her knee flare-up.

Melanie was treated with PRP injections and advised to rest and begin a gradual increase in activity as her pain allowed. At her six-week follow-up, this is what she had to say:

“I recently had my left knee fixed with Platelet-Rich Plasma and I am here to just give a real thumbs up to the process…It was a very good experience. I’ve had virtually no pain. I’m back up to walking 10,000 to 12,000 steps a day with no pain, no swelling. I’m just really, really happy with the results.”

Melanie also noted that her left foot and buttock pain had all but disappeared as well, and rated her knee as 98% better.

CASE #2 – PRP FOR PAIN, SPASMS, AND STIFFNESS

Mary was an active 70-year-old lady who had been an enthusiastic skier for 30 years. She began to experience severe pain, spasms, and stiffness in her inner thigh muscles and groin, particularly on the left side. As she put it, “I have been suffering with a condition that has completely befuddled every specialist I saw in the past four years. I have been to the heads of neurology, rehabilitation medicine, and neurosurgery in the biggest university- affiliated hospitals in the greater Chicago area, and even though I followed their instructions totally, it was all to no or very little avail. My condition remained a life-altering situation that restricted my daily activities to a serious degree, with always the aura of a possible groin or abductor spasm hanging over my head.”

Finally, after two or three epidural steroid injections, several months of physical therapy, a year of regular massage therapy and even Botox injection in her left inner thigh (not to mention years of muscle relaxants and sleeping with a heating pad on her legs), she came to see me and we discussed regenerative medicine. Mary tried four rounds of Prolotherapy, which provided fairly good relief, but her symptoms always slowly returned in a few months’ time. As she put it, Prolotherapy worked better than anything she’d done so far, but she still had “life-altering” dysfunction from her condition.

Mary eventually agreed to try PRP on the ligaments and tendons of her anterior groin/pelvis and hips. She stated that after two weeks, her pain was all but gone, and she said, “I have found a great improvement: to the point that I no longer worry about the dreaded spasms and am already leading a fuller and less restricted life.” She’s had one “touch up” injection since for some mild increase in symptoms, but to this day states that she has her life back as a result of PRP therapy.

CASE #3 – PRP FOR BACK PAIN

Since I know I’ve mentioned that I’m a patient as well as a provider of regenerative medicine, here’s one of my PRP success stories:

In the spring 2014, I “threw out” my back (in all likelihood suffered a disc bulge or protrusion in my lower back) and had all of the typical symptoms: pain, muscle spasm, tightness, etc. For days it was so bad that I had to consciously think about how to carefully stand or lie down so as not to provoke a back spasm. After about two weeks it began to subside and, rotten patient that I am, I thought that would be the perfect time to do some Tai Chi warm up movements and proceed to my Kung Fu forms that I’d had to put off. These latter forms involve a lot of quick, explosive muscle contractions…I’m sure you can see where this is going, right? Sure enough, not 15 minutes into my practice, my back seized up again, and I was back to square one.

As it happened, I was headed to a regenerative medicine conference in Florida later that week, but was in so much pain I almost cancelled.

While everyone else at the conference was heading to the sun and sand of the beach after lectures were over, I was spending hours heating and stretching my back every evening. On the third day, however, the physician moderators were doing a workshop for PRP and needed volunteers. My good friend Anna Stahl, who was my PRP kit provider, was able to get me in as a patient and I received my first PRP injections to my low back that evening. I won’t lie and say it didn’t hurt (my body’s natural pain amplifiers were already in full tilt before the inflammatory effect of the PRP went in, so it was a pain double whammy), but by dinner time my pain was at a tolerable level where I could actually enjoy conversation and a beer with friends.

The next morning, I awoke to find myself still somewhat sore and achy, but with no knee-jerk back spasms when I moved, and I could stand and walk normally for the first time in weeks.

The following morning the conference adjourned, and I had absolutely NO pain.

As I love the outdoors, I found a nearby state park and went on a 9-mile hike that afternoon, and the only pains I experienced were my shins and knees from the brambles that scratched me. That injection kept my back in good working order for over three years!

IS PRP ALLOWED IN ATHLETIC COMPETITION?

This is one of the more common questions athletes considering this treatment option ask. They rightfully don’t want to risk disqualification or banishment from their sport for taking any substance on the “black list.” The answer is YES! The World Anti-Doping Agency came out with this statement on the use of PRP:

“Platelet derived preparations (PRP) are not prohibited. Despite the presence of some growth factors, platelet-derived preparations were removed from the Prohibited List as recent studies on PRP do not demonstrate any performance enhancement beyond a potential therapeutic effect.”

In other words, PRP heals, and it doesn’t give you an unfair competitive advantage like steroids or blood doping (unless you consider healing faster and better than your competitors who stick to ice and NSAIDs a competitive advantage). For year-round athletes such as Olympic gymnasts, skiers, and decathletes whose sports pose a high risk of chronic injury due to pushing the body’s parameters to the physical limits, the option of a treatment such as PRP can be a godsend.

PRP AND VISCOSUPPLEMENTATION

There is also promising evidence that using PRP for knee pain in combination with hyaluronic acid (HA) injections (a thick, viscous liquid found in healthy knee joints that acts as a shock absorber and diminishes as we age) can lead to improved outcomes compared to PRP alone.

The injection of hyaluronic acid, called viscosupplementation, has been in use for over 20 years for treatment of knee pain from osteoarthritis. The hyaluronic acid not only acts as lubricant and a buffer to knee compression with weight bearing (think heavy weight motor oil), but there is evidence suggesting that it slows down the biochemical cascade of events that cause arthritis, and perhaps even stimulates the remaining cells in the knee that produce it to increase production.

I know I’m not the only regenerative medicine specialist who combines these two options with good results, and some recent studies have demonstrated the superior results of the use of PRP with HA compared to PRP or HA alone.

The result is what we call a synergistic effect: causing a result greater than the sum of the individual agents alone. In other words, 2 + 2 doesn’t equal 4 in this case; rather, 2 + 2 = 6. For patients who have intra-articular (joint) arthritis as one of their cases of knee pain, I find this combination to be an exciting option to offer.

WHAT ARE THE LIMITATIONS OF PRP?

As we mentioned before, the growth factors in PRP signal locally available adult stem cell, but, as one doctor put it, the signal is more like Bluetooth than Wi-Fi (i.e. of limited range). If there aren’t any available stem cells locally, then healing will be limited. As one expert rightly stated, “Chronic inflammation uses up the local repair [i.e., stem] cells.”

In other words, you can’t withdraw funds from an empty account. At this point, an alternate “fuel” is needed to effect improved healing,