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The pain has been increasing.  Physical therapy, massage, and stretching have not helped.  Your doctor recommends a PRP treatment.  What is PRP?  What are the different types of PRP?   How is PRP made?  What steps are important prior to PRP injection?  What is involved in the PRP injection process?  What to expect after PRP injection?  Let’s dig in.

What Is PRP?

PRP stands for Platelet-Rich Plasma.  Platelets are blood cells that prevent bleeding.  They contain important growth factors that aid in healing.  Plasma is the light yellow liquid portion of our blood.  So PRP is simply a concentration of a patient’s own platelets that are suspended in plasma and are used to accelerate healing.  PRP is NOT stem cell therapy.  Regrettably, blood contains few circulating stem cells.   Rich sources of stem cells are bone marrow and fat.

PRP is rich in growth factors.  There are many different types of growth factors with different properties. VGEF is a very important one as it can increase the blood flow to an area.  Blood flow brings important nutrients to damaged tissue and can stimulate repair and healing.  Regrettably, tendons, ligaments, and most parts of the spine have a poor blood supply (1).  This makes injuries difficult to heal.  PRP can facilitate repair and healing by increasing the amount of blood flow.

Are There Different Types of PRP?

There are two main types of PRP that are commonly used for injection (2).  The types are based upon the presence or absence of red and white blood cells.  Both types have high concentrations of platelets.

Red PRP is rich in white and red cells.  It is referred to as leukocyte rich (LR-PRP)

Amber PRP has very low quantities of red and white cells.  It is referred to as leukocyte poor ( LP-PRP)

 

 

How is PRP Made?

A PRP process involves several steps which are summarized below.

  1. Under sterile conditions, your blood is drawn typically from the arm or hand. Volumes drawn vary depending upon the number of areas to be injected and the concentration requested.
  2. At most clinics, the blood is placed into a centrifuge.  This is a machine that spins the blood causing it to separate.  Unfortunately, the centrifuge is limited in its ability to customize the PRP.   The result is a process where one size fits all.  At the Centeno-Schultz Clinic, we utilize a state of the art laboratory with cell biologists on staff that can customize the volume and concentration of the PRP.  In this way, you get a very specific and personalized PRP intended for your personal needs.  PRP concentration matters.   We have published our own research demonstrating that higher concentrations of PRP were more effective in tendon healing in older patients (3).

To learn more about the different types of PRP please click on the video below.

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How Do I Prepare for the PRP injection?

Before we get into what to expect after PRP injection, you need to know how to prepare, as preparation is one of the keys to clinical success.  At the Centeno Schultz Clinic, our PRP pre-procedure guidelines are as follows.

  • Stop all anti-coagulations.  These medications such as Coumadin and Eliquis can cause excessive bleeding
  • Stop NSAIDs.  NSAIDs such as Motrin, Voltaren, and Ibuprofen can reduce stem cells and cause platelet dysfunction.
  • Stop all oral steroids 2-4 weeks prior to the procedure.  Steroids such as a Medrol Dose Pack and cortisone can negatively affect platelet function.

The PRP Injection Process

The use of PRP in the treatment of different conditions continues to expand.  The most common conditions include sciatica, knee arthritis (4), tennis elbow, Achilles tendinopathy, low back pain, and rotator cuff injuries.

Once the PRP is prepared it is injected into the targeted tissue. For example, in a patient with a patellar tendon tear, it is important that the PRP be injected into the tendon tear.   How it is injected is critical.  At the Centeno-Schultz Clinic, all injections are performed with either ultrasound or x-ray guidance, or both.  Accurate placement of the PRP  requires guidance.  Blind injections are substandard and should not be tolerated in 2020 as there is no assurance of the PRP getting into the damaged tissue.

Medications to avoid that regrettably are commonly mixed with PRP include:

Toxic local anesthetics:  not all anesthetics are the same and some are toxic to cartilage and stem cells (5).

High dose steroids:  steroids are toxic to cartilage (6).

What to Expect After PRP Injection

What to expect after PRP injection is incredibly important. The PRP injection recovery time varies depending on the area of your body that’s been treated as well as the severity of your condition or injury.  For example, joint injections are typically less painful and respond quicker than injections into the tendons, ligament, and muscle injuries.  Because PRP injections are intended to promote healing or growth, you may not notice an immediate difference after receiving the injections.  The PRP injection recovery time can be affected by the following factors:

The Site of Injection  

PRP recovery time of injections into the joint (intra-articular) are fairly quick with only 3-5 days of soreness and possible swelling.  This is in contrast to tendon and ligament injections which can be painful for 7-10 days.  Thereafter the improvement is gradual and can take up to 3-4 months.

The Severity of Injury

The more severe the joint, tendon, or ligament injury or underlying condition the, longer the potential PRP injection recovery time.

Number of Sites Injected

If multiple tendons, ligaments, muscle, and joints are injected this can potentially prolong the PRP injection recovery time.  How?  It can potentially limit one’s activity and ability or willingness to engage in PT in the short term.

Activity

The initial phase is rest with mild range of motion.  Activity is gradually increased thereafter with the goal of minimizing swelling and pain.  The protocol will be specific to the underlying condition that is being treated.

Bracing

Bracing is important in many types of injuries as it provides support to the affected joint and allows healing of tendons, ligaments, and areas of cartilage.  An example is a knee unloader brace that provides support for the knee and allows healing.

Rehabilitation

A critical part of any treatment is post-procedure rehabilitation. The protocol will be specific to the underlying condition that was treated.  For example, the rehab protocol for a kneecap pain will be much different than that of a rotator cuff tear. The initial phase is rest with a mild range of motion.  Thereafter focus is on strengthening, neuromuscular control, and range of motion.

Tendon and ligament healing occurs in three phases.  Inflammation is the first phase and typically lasts 1-2 weeks.   New, disorganized tissue is laid down during the second phase which lasts 2-6 weeks.  The new tissue is then reorganized and made stronger during the third phase which occurs from 6 weeks to 6 months.

To learn more about ligament and tendon healing after PRP please watch the video below.

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In Conclusion

PRP stands for Platelet-Rich Plasma. It is a concentration of a patient’s own platelets that are suspended in plasma. The two major types of PRP are Red PRP and Amber PRP.  PRP is made by spinning down a patient’s blood whereby the red and white cells are separated and the platelets are concentrated. Preparation is essential and requires discontinuation of anticoagulants, NSAIDs, and steroids. For the best clinical outcomes, the PRP is injected under ultrasound or x-ray guidance for accurate placement into damaged tissue. What to expect after PRP injection depends upon multiple factors which include the site of injection, the severity of the injury, and the number of sites injected.  The level of activity, bracing and rehabilitation protocol is dependent upon the specific injury.

PRP is an effective treatment option for many musculoskeletal injuries.  Knowing what to expect is essential for the best clinical results.

 

References


1.Mishra A, et al. Treatment of Tendon and Muscle Using Platelet-Rich Plasma. ClinCports Med 2009; 28:113-125.2. Cook JL, et al. Is Tendon Pathology a

2. Mautner K, Malanga GA, Smith J, Shiple B, Ibrahim V, Sampson S, Bowen JE. A call for a standard classification system for future biologic research: the rationale for new PRP nomenclature. PM R. 2015 Apr;7(4 Suppl):S53-S59. doi: 10.1016/j.pmrj.2015.02.005.

3.Berger DR, Centeno CJ, Steinmetz NJ. Platelet lysates from aged donors promote human tenocyte proliferation and migration in a concentration-dependent manner. Bone Joint Res. 2019;8(1):32–40. Published 2019 Feb 2. doi: 10.1302/2046-3758.81.BJR-2018-0164.R1

4.Xing D, Wang B, Zhang W, Yang Z, Hou Y1,2, Chen Y, Lin J. Intra-articular platelet-rich plasma injections for knee osteoarthritis: An overview of systematic reviews and risk of bias considerations. Int J Rheum Dis. 2017 Nov;20(11):1612-1630. doi: 10.1111/1756-185X.13233.

5.Dregalla RC, Lyons NF, Reischling PD, Centeno CJ. Amide-type local anesthetics and human mesenchymal stem cells: clinical implications for stem cell therapy. Stem Cells Transl Med. 2014;3(3):365-374. doi:10.5966/sctm.2013-0058.

6. Wernecke C, Braun HJ, Dragoo JL. The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review. Orthop J Sports Med. 2015;3(5):2325967115581163. Published 2015 Apr 27. doi:10.1177/2325967115581163