Practical PRP. My experience with Platelet Rich Plasma

Transcription

1 Practical PRP My experience with Platelet Rich Plasma PRP is a promising therapy for all patients with musculoskeletal ailments. This therapy can treat patients with strains and arthritis in all joints including shoulders, elbows, lumbar spine, knees, and ankles. The results speak for themselves. 80 to 85% of patients notice improvement in their musculoskeletal complaints. Many of the patients have almost complete resolution of their complaints. Many of these patients are now able to perform activities such as gardening and walking where they could not prior to PRP treatment. Many of them are taking fewer pain pills which is overall a healthier state and many are now sleeping through the night where they couldn t before. The types of patients I've treated are patients coming in complaining of musculoskeletal issues. Many of them have had chronic lower back pain, chronic knee pain and hip pain. The pains could have been present for a couple months or 5 decades. Some of them have had prior surgery with or without instrumentation on the joints whether it be knee or lower back. Many of them have now fallen into a gap in therapy in which they have no adequate solution to resolve their chronic pain. Many are on chronic pain medicines and anti-inflammatories which have inherent risks. They are also not surgical candidates or they do not want to undergo surgery. Many have tried physical therapy, however this option has only helped to a certain extent. There continues to be a large gap in the treatment options for these patients between taking oral medicines or straight to an extensive, risky surgery. Platelet rich plasma can seriously fill this gap in treatment options. My experience has been that patients who have been injected with PRP have found that their pain is dramatically reduced and their joints have become much more stable allowing them to decrease their pain medicine consumption and become more active. Many of these patients had no hope for any kind of further treatment because they were on maximum medications, often the medications upset their stomachs, or patients did not want to continue on medication and were not interested in surgery or incapable of undergoing the surgical intervention. I consider platelet rich plasma to be a regenerative joint therapy. When a person has injured their joints they have caused damage to the ligaments and tendons. When the tendons heal they heal stretched. This causes an instability in the joint. The body does not like this instability and tries to recruit the muscles above and below the joint to stabilize the joint. Muscles are not designed for constant use and they fatigue and become spasmed and painful. This is where a lot of people get chronic lower back pain and chronic thigh and lower leg pain from the knee joint, for example. Moreover, the body's response to the instability and the tendinosis of the ligaments and tendons around the joint is to start to calcify those ligaments and tendons creating the bone spurs that we often see on x-ray and consider to be DJD of the various joints. When we use platelet rich plasma we inject into the ligaments and tendons and sometimes into the joint space such as in knees and shoulders to create a healing cascade which starts to thicken and strengthen

2 the tendons surrounding the joint. The platelets have granules which have a number of growth factors within them. When the platelets are injected into the ligaments and tendons they initially release the growth factors which start an inflammatory cascade and thus a healing cascade. These growth factors then call in white cells which clean up any debris in the ligaments. After about another week the white cells then call in stem cells which will then strengthen the fibroblasts and lay down thicker and stronger collagen. This has been demonstrated in animal models 1,2. Initially, platelet rich plasma was used by oral surgeons and plastic surgeons to enhance healing when they did reconstructive surgery. In the early 2000 s, sports athletes started using platelet rich plasma to heal their injuries more quickly and get back in the game more quickly without having significant surgery and rehab time. Now that platelet rich plasma is easy to harvest, it is an excellent therapy for the average person whether they have sports injuries or chronic arthritic injuries and changes. The procedure is quite simple. I use the Harvest, Inc. SmartPrep kit and centrifuge which concentrates the platelets to 5 times the whole blood concentration. We draw 20 to 60 cc from the patient's vein. This blood is then placed in a special container which goes into a special centrifuge and spun for about 15 minutes. The platelets and plasma are separated from the red cells. The excess plasma is then removed and a concentrated platelet rich plasma remains. While the platelet rich plasma is centrifuging, I will anesthetized the patient's joint. I concentrate on the ligaments and tendons involved with the patient's injury which are often the most painful sites surrounding the joints using a Prolotherapy injections type technique. Common injection areas are the iliolumbar ligaments and SI joints in the lumbar spine the rotator cuff ligaments around the shoulder and the various ligaments stabilizing the knee. The patients experience some soreness after the procedure when the anesthetic has worn off. The soreness may last 24 to 48 hours. Sometimes the shoulders last a little bit longer. However, immediately the patients start noticing a strengthening of the joint and a stabilizing that they had not noticed before. My routine follow-up time is six weeks after the injection because I believe that gives enough time for the platelet rich plasma to go through the healing cascade. At that time we can more thoroughly assess the results of the treatment and decide if the patient requires more injections. The number of injections have ranged from 1-4. Most common is about 1-2. I rarely have done four injections. Multiple different factors are involved with the requirement of repeat shots which include the damage that has been done to the joint and the inherent capacity of the patient to heal. About 80 to 85% of the patients have had good results. I define good results by a reduction of pain, reduction in pain medicine consumption, more physical activity that they had not been able to do before, and sleeping better at night. These patients are overall satisfied with the procedure and would recommend it to other patients. In a retrospective study that I conducted, I demonstrated pain reduction and overall satisfaction with the procedure. The data are included with this paper. The procedure is very safe outside of injection risk. There are no external chemicals used except a calcium citrate anticoagulant added to the platelet rich plasma mixture. The patients like the concept of using a naturally healing therapy with their own blood to help their chronic condition.

3 I use this therapy when patients have been complaining of chronic pain for more than a couple months. The pain is usually moderate to severe and the patients have become discouraged and would like some type of resolution. Often, I will offer them an option of physical therapy but the patients do not want to take the time and the involved expense to do the physical therapy as well as the expectation that the therapy will take one or two more months of discomfort before they see results. This therapy is more cost effective than physical therapy and easily more cost effective than surgery. With one or two injections I have been able to get patients to a more reasonable level of pain or out of pain. At a minimum, if they get some results they have better function. Research has been ongoing with PRP for years. With respect to animal studies, PRP was shown by Hammond, et al to heal acutely injured rat muscle faster than without 1. In another model, rabbit patella tendon was injured by carving a gap in it and filled in with PRP. This study showed the tendon to heal better, faster with PRP, and had more angiogenesis earlier in the healing. The fibers that grew had more elasticity 2. Human studies have been done on tennis elbow, patella tendon and planter fasciitis. Mishra showed healing of tennis elbow in 2004 in patients that had recalcitrant lateral epicondylitis for longer than a year 3. Kon, et al showed healing in patella tendon injury. The patients had the injury for more than 1 year and had been through many different therapies which had not helped. Two treatements of the patella tendons in these 20 patients resulted in 85% healing 4. Plantar fasciitis is healed better with PRP according to Barnett 5. Finally, Peerbooms in the Netherlands this year, in a study of lateral epicondylitis has shown much better healing with PRP compared to cortisone in a double blind study of 100 patients. His definition of success was no further treatment for 1 year and a reduction in pain of 25%. He showed the PRP to have a 73% success rate compared to 51% in the cortisone treatment arm. He noted that the cortisone patients got better more quickly but then plateaued whereas the PRP patients continue to improve with time 6. This is expected considering the healing cascade that the PRP initiates when it is injected. To get a better feel for the effectiveness of PRP, I conducted a retrospective study of my patients that had undergone PRP. The idea was to gather information on the effectiveness, what injuries to treat, and an the patient types to treat. This was compiled from April 2009 through April It includes 112 patients ranging in age from 18 to 90. This was a 66% response rate to the total number of patients surveyed. The average age was 59. One hundred twenty nine joints were treated comprising 43 lumbar spines, 40 knees, 18 shoulders, 14 hips, 5 ankles, 3 wrists, 2 thumbs, 2 cervicals, 1 thorax and 1 achilles. The patients were asked to fill out a retrospective questionnaire that included the following information: 1. Age 2. Amount of time in pain before the PRP injections. 3. Number of shots per joint scale of pain before and after injections. 5. Percent improvement. 6. Satisfication with the procedure.

4 7. And would they recommend the procedure. The data showed an average age of 59. The patients were in pain ranging from a couple months to 50 years. The average time in pain was 57 months. The average number of shots per joint was On a scale of 1-10, the patients started out with an average pain of 8.0 and finished with an average pain level of 3.6 after injections. Time to relief was a couple days to a couple months. When the patients were asked to rate their percent improvement, they gave an average of 57% improved. When asked to rate their satisfication, 53 patients(50%) were very satisfied, 27patients(25%) were satisfied, 11 patients(10%) were somewhat satisfied, and 16 patients(15%) were not satisfied. Finally, 87.5% would recommend the procedure, 10.7% would not recommend and 1.8% were not sure. I then broke the data down by Medicare patients which included 36 patients. This was a 57% response rate for the medicare population. The age range for the patients was 57 to 90 years old with an average age of The average number of shots per joint was The average percent improvement was 62%. Number of patients needing more than three shots was only three patients. The joints that were treated were 21 lumbar, 14 knee, 6 shoulder, 7 hip, one cervical, and one ankle. 58% of patients were very satisfied and 22% were satisfied with 17% being somewhat satisfied. Only 2.8% or one patient was not satisfied. Only 11 percent or 4 patients got less than 20% improvement with the PRP. Eight patients or 22% were considering surgery before the PRP but did not need it after. Patients had pain anywhere from a couple months to 50 years with an average time of five years and three months of pain in the affected joint before having the PRP injection. Several patients had surgery on their joints prior including lumbar laminectomy with plates and total knee replacements. With respect to activities of daily living people described less pain, able to walk better, able to sleep better, able to do more activities around the house such as gardening and housecleaning with much less pain. Also, they described recovery after activity being quicker compared to before when they had done activities. I think the important factor is that these patients overall improved with PRP treatment which is very safe and effective and minimally invasive. Moreover, eight patients who were considering surgery for their joints are now able to live an active lifestyle with much less pain and avoid the surgery with all its complications and costs, both for the medical system and for the patient. I have included a couple case studies: Case Study #1- Abraham M. Today s society sees more joint issues than before. This is due to the fact that we are a more active society and we are living longer. There is more trauma from work, sports and general life activities. People enjoy their active lifestyle for multiple reasons, including physical and emotional well being. When a person is injured and the healing process doesn t finish, joints remain painful and dysfunction ensues. Some patients experience depression and anger. This case study demonstrates how Platelet Rich Plasma is a potent, safe, and natural therapy to restart thehealing process in injured joints and help people return to their prior active lifestyle.

5 Abraham was an 18 y/o male who came to me on January 19, 2010 for an initial consultation for PRP for his right knee. He had originally injured the knee on November 7 th, The injury occurred during a soccer game when he planted his foot and turned without the lower leg moving. He developed considerable pain and swelling in the knee and had to stop playing. He saw an orthopedic surgeon who obtained an MRI on November 30 th of the knee which showed the medial collateral ligament having a grade 1 sprain without full thickness tear. There was bone contusion of the lateral femoral condyle and effusion of the lateral knee joint. The radiologist also read a possible partial tear of the anterior cruciate ligament to be correlated with physical exam. The MRI also mentioned a posterior horn tear and body tear of the lateral meniscus. The orthopedic surgeon recommended arthroscopy. The patient s mother did more research and found that PRP might help sprains and came for an opinion regarding its use. On initial exam in my office, the right knee was tender along the MCL and medial anterior joint line. The knee had diffuse effusion. The lateral joint line was not tender to palpation. He had considerable gapping of the medial joint with valgus and negative drawer line. The risks and benefits were discussed with the patient and he opted to have the PRP done. For this treatment, I used a large 60cc Harvest SmartPrep kit. I felt the larger amount of PRP obtained from this amount of blood would be better for treating themultiple areas of the knee that needed treated. I anesthetized the MCL, the anteromedial joint line, the anterolateral joint line, the lateral joint space into the anterior cruciate ligament and the medial joint space into the ACL and the tibia plateau. I used about 20cc of mix of lidocaine and marcaine. I then injected the PRP into the above areas using a peppering technique of the ligaments and tendons around the knee and within the knee. The patient tolerated the procedure well and was given home care instructions with some vicodin. He was asked not to do any exercise, such as running and turning. For follow-up, I called the patient the next day to see if he had any discomfort from the injections. He stated he felt fine and had very little discomfort. I had him return in 4 weeks to check his knee function and see if he needed another PRP. On exam, he had no effusion. He had no tenderness. He had mild gapping of the medial joint with valgus but much less than on initial exam and no pain with valgus. He had normal flexion and extension. At this point, I had him resume regular activity with soccer and other sports and notify me if any pain of instability develops. I also obtained an MRI on February 24 th. I had it compared to the prior MRI from November. The comparison revealed no more effusion. There was no bone contusion. The ACL was thickened at its femerol insertion but appreared intact. The medial collateral ligament was now normal. The posterior horn of the lateral meniscus still had evidence of a tear. On further followup, I called Abraham on He was playing soccer normally without any pain. His knee was stable but he was still being cautious when cutting and turning. He did not experience any swelling. This case reperesents a typical result of Platelet Rich Plasma therapy. My experience is that 80% of patients find improvement with injections of PRP. While this case involves the knee, I have found equal success with virtually all other joints in the body. What is remarkable with this case is the fact that we achieved resolution of the patient s pain and documented healing of the MCL tears, the bone contusion, and the joint effusions with MRI. Platelet Rich Plasma therapy holds the potential to help the millions of patients with joint injuries whether from sports or aging to get back to a more active life. Case #2- Shoulders and knees.

6 D.L. is a 50 year old male with a long history of bilateral shoulder pain. The pain was disabling and stopped the patient from doing many activities and working around the house. He had done strengthening for the shoulders but still had significant dysfunction and pain. His past medical history was significant for being a retired Navy seal and has had the pain since active duty. One of his biggest issues is when he folded his hands behind his head, his shoulders got locked up and he needed assistance from his secretary to return his shoulders to a normal position. DL underwent his initial PRP on the right shoulder on May 28. His shoulder was anesthetized and injected with 10cc of PRP along the biceps tendons, anterolateral joint capsule, lateral joint capsule, and posterior joint. His AC joint was also injected. He was rechecked 2 weeks later and was doing much better. He opted to have the left shoulder injected on June 9. A similar injection technique was used. He was rechecked on October 16. He stated that the shoulders had never felt better. He was much more physically active and exercising daily. But the right shoulder could still use some treatment. He felt pain with abduction and external rotation. Another PRP treatment was done at that visit. DL had been in periodically since the last treatment. His shoulders give him no more pain. He can do physical work at home and at work without the shoulders bothering him. He can fold his hands behind his head and return to a normal position without assistance or pain. His last visit was May 14. He was using less pain medicines and starting treatments for his knees. On May 14, DL received a PRP treatment to his left knee. He had been having pain in the knees for years. About 3 months prior, he had to stop running because of the pain and swelling in the knees. He was only comfortable with walking. The treatment I did on his knee was a general treatment of the entire knee including the MCL, medial joint line, medial patella, lateral joint line, LCL and some under the patella. This is very general treatment using a larger PRP kit. Often, in cases such golfers knee, in which the medial side of the knee is injured, I will use a smaller kit and concentrate on the medial components and get great results. On June 4 th, DL returned for PRP on the right knee. His left had no pain or swelling and he could be very active on the knee without pain. We treated his right with a similar treatment and are waiting 6 weeks to recheck the results. Case #3-J.M.- Lumbar pain after surgery. JM, a 69 year old female, had lumbar spine surgery the year before consulting me. She had chronic back pain for years before the surgery and was still having bilateral lower back pain which radiated into the buttocks. She was using chronic pain medicines because of the back pain and knee pain. Her activity level was as high as possible with some swimming in other activities but she was still not satisfied with her activity level since she was limited by the pain. She was only getting four hours of sleep at night and awakening constantly. Her pain level was

7 On exam for her first visit she had central lower back scar consistent with her surgery. It extended from the upper lumbar to the lower lumbar. She had bilateral iliolumbar ligament pain and sacroiliac pain. I performed a platelet rich plasma treatment on her using about 10 1/2 cc of the PRP split between both sides. I injected the bilateral iliolumbar ligaments and sacroiliac joints after anesthetizing her with lidocaine and Marcaine. I was careful to stay lateral to the incision area and along the bone of the ileum and into the sacroiliac joint. She came back for recheck one month later and had noted that she immediately had awakened with no back pain. She is able asleep a full night and get seven hours of sleep. Her pain was now down to level She had only recently started noticing some increasing pain. She was doing all of her prior exercises with no pain difficulties. She was able to decrease her pain medicine consumption. At the second visit we again performed a platelet rich plasma injection on the bilateral iliolumbar ligaments and SI joints. Follow-up survey about one month after the last injection showed the patient to have 90% improvement. Her pain level was staying at a level 3. She is able to sleep, walk, sit, and stand which she was not able to do comfortably before. She was very satisfied with the treatments and recommending them to anybody she could. Case study#4-low back and knees. KW is an 80 year old male with bilateral lower back pain and bilateral knee pain. His lower back pain is the result of an accident over 50 years ago while ferrying a B-17 across the U.S. He hit some turbulent air in a storm and was thrown around while trying to secure some material. He injured his lower back then and had had chronic pain since. When he walked 100 yards at his job from his office to the bus he drove, he had to stop several times because of severe lower back pain radiating to the legs with numbness in the legs, as well. His knees had arthritis and he had the left one replaced several years ago. He was hoping the PRP treatments for the right knee would give him relief and prevent a replacement. The first PRP treatment, on Feb 18 th, was to the bilateral lower back using a 60cc kit. I injected the iliolumbar ligaments, the sacro-iliac joints, and the sacro-coccygeal ligaments. He did very well and had little pain the next 2 days. KW followed up on Feb. 26 th for the right knee. His lower back was much better with a little soreness. We treated the medial right knee and saw the patient on April 1 st. On April 1 st, his main complaint was his lower back pain had regressed. He had been doing well, but in the last 3 weeks, he had increasing pain with walking. He was much better but was getting the leg pain again. On April 1 st, we treated his bilateral lower back again. He came back again on April 22 for the right knee. The back was much improved. He was walking better and more active. We treated the right knee again on the 22 nd. Patient returned for recheck on May 13 th. At this point, the right knee was much better. He had very little pain and much more stability. He stated that he wished this treatment was available years ago before he had his knee replaced. He probably would have avoided a knee replacement. His lower back was improved but still having some pain at the base. He could walk the 100 yards with a little tingling in the right leg but not the amount of pain as before. He did not have to stop like before.

8 On May 13 th, KW had another lower back PRP to see if he could get the remaining pain resolved. On June 4 th, we completed another right knee treatment. His right knee was over 50% better and he wanted to see how much more improvement after this treatment he could achieve. Overall, KW is very pleased with the PRP. He now is able to walk his dog without much pain. He is more mobile and active and doesn t need to think about pain with his movements. His decades of back pain is dramatically reduced. Case study # 5 Mary R. This case is interesting because it shows the healing power of PRP. Mary R. is 70 year old Hispanic lady, long time patient of mine, who has had diabetes for over 30 years and was placed on dialysis about eight years ago. She came to me complaining of both of her knees bothering her in Initially, I did prolotherapy for the left knee. She responded okay to the prolotherapy so I tried PRP on her two weeks later. She had some medical issues in the intervening weeks and had another PRP done on the left knee about two months later. At this point the left knee was doing very well and had very little pain. She was able to walk on it much longer distances. She then pursued the right knee. The right knee required 2 PRP injections with a subsequent prolotherapy injection couple months after the last PRP injection. Patient did very well with the right knee. And she was pain-free a couple weeks after the injections. The knees have remained relatively pain-free and she is much more mobile. It is now six months after the last PRP injection in the right knee. His approximately 10 months after the last PRP injection for the left knee. Overall, she's very satisfied with therapies. This case shows the effectiveness of PRP and the power of its ability to generate healing despite having someone with significant chronic medical conditions.

9 Bibliography 1. Hammond Jason, et al. Use of Autologous Platelet-rich Plasma to Treat Muscle Injuries, American Journal of Sports Medicne 2009;10: Lyras D, et al. Immunohistochemical study of angiogenesis after local administration of platelet rich plasma in a patellar tendon defect. International Orthopaedics 2009;11 February: online. 3. Mishra, Allan et al. Treatment of Chronic Elbow Tendonisis with Buffered Platelet Rich Plasma. American Journal of Sports Medicine 2006;10: Kon, E. et al. Platelet rich plasma: New clinical application. A pilot study for treatment of jumper s knee. Injury, International J. Care Injured 2009;40: Barret, S et al. Growth Factors for Chronic Plantar Fasciitis. Podiatry Today 2004;November: Peerbooms, J. et al. Positive effect of an Autologous platelet concentrate in lateral epicondylitis in a double blind randomized controlled trial:platelet rich plasma versus corticosteroid injection with a 1 year follow-up. American Journal of Sports Medicine 2010; 38: Joseph Aiello, D.O. I would like to thank my research assistant, Megan Sage, for her extensive help compiling the data for this study.