According to the World Health Organization (WHO), musculoskeletal injuries are the most common cause of severe long-term pain and physical disability, and affect hundreds of millions of people around the world (1). This has increased the interest in research for safe and effective treatment for musculoskeletal injuries.
The last decade has brought about significant advances in musculoskeletal injury repair, including concentrated autologous platelet-rich plasma (PRP) therapy (2)(3).PRP is a form of Stem cell therapy in which the blood of the patient of person is taken to harvest the platelets and plasma and hence the term “Autologous” is used. PRP is an emerging treatment in a new health sector known as “Orthobiologics.”
Blood is made of RBC (Red Blood Cells), WBC (White Blood Cells), Plasma, and Platelets. PRP is a fraction of autologous whole blood centrifuged and containing an increased number of platelets and a wide variety of cytokines such as platelet derived growth factor (PDGF), vascular endothelial growth factor (VEGF) and transforming growth factor beta-1 (TGF-B1), fibroblast growth factor (FGF), Insulin-like growth factor-1 (IGF-1) among many others. Autologous platelet-rich plasma (PRP) is a relatively new biotechnology backed by over two decades of research in diverse areas.
In other words Platelet Rich Plasma is defined as a volume of the plasma fraction of autologous blood having a platelet concentration above baseline (4)(5). Normal platelet concentration is 200,000 platelets/ul. Studies have shown that clinical efficacy can be expected with a minimum increase of 49 this baseline (1million platelets/ul) (6). Slight variability exists in the ability to concentrate platelets, largely depending on the manufacturer’s equipment. However, it has not been studied if an increased platelet concentration would have paradoxical effects(7).
Platelet Rich Plasma Effects
PRP’s healing properties result from its ability to release growth factors and chemo-attractants, congregating macrophages and fibroblasts to the site of injury to facilitate tendon repair (2). The growth factors found in platelets have been shown to be key in the reparative process of tendons (8).These Platelets Derived Growth Factors (PDGF) stimulates cell replication, promotes angiogenesis and promote epithelialization(7). Initially platelets were thought to act exclusively with clotting. However, we have learned that platelets also release many bioactive proteins responsible for attracting macrophages, mesenchymal stem cells, and osteoblasts which not only promotes removal of necrotic tissue, but also enhances tissue regeneration and healing. Based on this principle platelets are introduced to stimulate a supra-physiologic release of growth factors in an attempt to jump start healing in chronic injuries. The current literature reveals a paucity of randomized clinical trials. The existing literature is filled with mostly anecdotal reports or case series, which typically have small sample sizes and few control groups (9)(10).A large multi-center trial is currently underway providing a more objective understanding of Platelet Rich Plasma (PRP).
Uses of Platelet Rich Plasma
The use of autologous PRP was first reported in 1987 by Ferrari et al. (11) following an open heart surgery, to avoid excessive transfusion of homologous blood products. Since that time, the application of autologous PRP has been safely used and documented in many fields including; orthopedics, sports medicine, dentistry, ENT, neurosurgery, ophthalmology, urology, and wound healing; as well as cosmetic, cardiothoracic, and maxillofacial surgery. Studies suggest that PRP can affect inflammation, postoperative blood loss, infection, narcotic requirements, osteogenesis, wound, and soft tissue healing. In addition to local hemostasis at sites of vascular injury, platelets contain an abundance of growth factors and cytokines that are pivotal in soft tissue healing and bonemineralization(12) . An increased awareness of platelets and their role in the healing process has lead to the concept of therapeutic applications.
Recently PRP have gained a considerable interest in sports medicine field and in knee osteoarthiritis. This is becausePRP products are safe and easy to prepare and administer, there has been increased attention toward using PRP in numerous clinical settings and due to its effect on acceleration of healing it leads to rapid recovery and return to game which is of prime most importance for a sportsperson. The World Anti-Doping Agency (WADA) banned intramuscular PRP injections in competitive athletes in 2010 because of concerns that it may increase performance-enhancing growth factors. The ban on PRP was removed in 2011 because of limited evidence for a systemic ergogenic effect of PRP, but the growth factors within PRP remain prohibited(13) . Platelet-rich plasma has been used to treat conditions such as lateral epicondylitis, ligament and muscle strains, and tears of the rotator cuff, anterior cruciate ligament, and Achilles tendon.
Conditions commonly treated with Platelet Rich Plasma
Rotator Cuff Tendinitis or Tear, Rotator Cuff Impingement Syndrome or Bursitis, Bicipital Tendinitis, labrum tears, arthritis, instability
DeQuervaine’s Tenosynovitis, arthritis, other wrist or finger tendinitis, ligament tears or dysfunction of the fingers
Medial and lateral epicondylitis (tennis & golfers elbow)
IIliotibial Band Tendinitis (ITB Syndrome), Psoas Tendinitis and bursitis, Greater Trochanteric Bursitis, Hip labrum tears, Piriformis Syndrome, Sacroiliac Joint Dysfunction, arthritis
Patellar Tendinitis, Patellar Femoral Syndrome, chondromalacia patella, partially torn or strained major ligaments of knee (ACL/LCL/MCL), meniscus tears, arthritis, patellar instability
Achilles Tendinitis, Peroneal Tendinitis, arthritis, recurrent ankle sprains, other foot or ankle tendinitis
Conditions considred for treatment with Platelet Rich Plasma
Whiplash injuries, headaches related to the neck, arthritis
Facet joint arthritis, rib problems, pain associated with scoliosis
PRP Preparation and administration
PRP is prepared by withdrawal of patients' peripheral blood and centrifugation to obtain a highly concentrated sample of platelets, which undergo degranulation to release growth factors with healing properties. It also contains plasma, cytokines, thrombin, and other growth factors that are implicated in wound healing and have inherent biological and adhesive properties. The prepared concentrate is then injected back into the patient at the site of morbidity. This may be intralesional, intra-articular, or surrounding the involved tissue bed(14).
It is injecting under ultrasound guidance and making the skin and the part numb .Cold spray is used to numb the superficial skin and anesthesia for the part/parts to be treated,mostly Lignocaine is used. PPR is also available in gel form too.
Considerations for administration of Platelet Rich Plasma
- · The area of the body being treated
- · The overall health of the patient
- · Whether the injury is acute (such as from a fall) or chronic (an injury developing over time
- · volume of injection/application,
- · most effective preparation,
- · buffering/activation,
- · injection technique (1 depot vs multiple depots),
- · timing of injection to injury,
- · single application versus series of injections, and
- · the most effective rehabilitation protocol to use after PRP injection
Treatment with PRP hold promises. It is being widely used but still the sure shot claims in media my medical fraternity are lacking. This may be because many of the results are seen on animal samples.The medical community needs more scientific evidence before it can determine whether PRP therapy is truly effective inmultitude of injuries/disorders that are thought to benefit from PRP. Because there are conflicting studies present in PRP therapy, by which we can say that the therapy is still questionable. One of the recent studies for PRP injection in acute knee osteoarthiritis showed decrease pain index and improved functional and clinical score but showed no changes in MRI(16). After all the ‘if and buts’ PRP have minimal risk for sure which include only pain at the site of injection.
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