Because the goal of PRP Injection is to resolve pain through tissue regeneration, it takes time for the regeneration to happen. Some have suggested that this process mirrors the phases of wound healing, which can take up to 100 days to a full year. There are 3 primary phases, the inflammatory, proliferative and maturation phases.
The inflammatory and proliferative phase overlap in the first 1-3 days, starting with inflammation then deposition of granulation tissue, then wound contraction occurs over the first 30 days. It is felt that this day 10-30 is when collagen accumulation and remodeling occurs, then the process moves into the maturation phase.
The maturation phase is when extracellular matrix is laid down primarily through accumulation of type I collagen which is the foundation of healthy tendons, this phase can last for several months up to one year.
It follows then that initial improvement from PRP Injection may be seen within a few weeks, gradually increasing over 3-6 months, even up to one year as the healing and regeneration progresses. This is quite a bit different than a "Steroid Shot" which tends to make you feel better within a few days but often this wears off within a few weeks and the pain is back. Both ultrasound and MRI imaging have shown definitive tissue repair after PRP Injection, confirming a regenerative response. The need for surgery can also be greatly reduced by regenerating tissues before the damage progresses beyond repair. Surgery often involves debridement and removal of tissue, whereas PRP hopes to repair and regenerate your own tissue. PRP is not magic, and not all patients respond, there are still ongoing studies some positive and some not so positive. There are many variables such as preparation system, presence of RBC's and WBC's, concomitant needle tenotomy, use of lidocaine type anesthetics, among others that might affect the final results and over time some of these questions will be answered.
The PRP therapy takes approximately 1.5 hour to complete, including blood draw, preparation of the PRP by spinning in a centrifuge and injection time. This entire process is performed safely in a medical office. A convenient in-office procedure that avoids the risks of surgery, general anesthesia, or hospital stays and without a prolonged recovery. In fact, most people return to their jobs or usual activities right after the procedure.
Platelet rich plasma therapy (or PRP injections) is an innovative treatment approach that uses your body's own platelets to promote regeneration and repair of musculoskeletal tissue such as ligament, tendon or cartilage. Some of the conditions PRP injections have shown benefit for are:
Deliverable platelets are the actual volume of viable platelets contained in a PRP sample. A 2 spin protocol PRP provides between 7.5 and 9.5 trillion platelets in a 7mL treatment sample. High volumes of deliverable platelets enhances the volumetric activity of platelet growth factors and cytokines in active tissue repair, however there are some concerns that the higher Leukocyte content of this type of sample may be more inflammatory and have more catabolic (cell damaging) growth factors. Platelet alpha granules contain various platelet growth factors that promote tissue repair along with platelet cytokines that provide the chemical stimulus needed to attract and direct reparative cells to injured tissue.
Neutrophils are the most abundant leukocyte and one of the first-responders to migrate towards a site of injury or infection (chemotaxis). Neutrophils are also the hallmark of acute inflammation. This is an aggressive response of chemical signals from cytokines such as interleukins (IL-1, IL-8) and tumour necrosis factor alpha (TNF-α) along with many others. The primary function of the neutrophil is to engulf and destroy foreign material through phagocytosis. Under normal circumstances, neutrophils are short lived (1-2 days) and are cleared by tissue macrophages. In conditions where the neutrophils cannot be cleared, for a lack of macrophages, they undergo a process called necrosis resulting in the release of all of the intracellular contents. This causes the amplification and prolonging of the inflammatory response. This prolonged amplified inflammatory response potential, is a concern of many physicians. This is why physicians are not encouraged by a PRP product containing high concentrations of neutrophils.
Monocytes are the largest of all leukocytes and are characteristically non-inflammatory phagocytic cells. Monocytes migrate to sites of injury and infection and differentiate into macrophages and dendritic cells to elicit an immune response which last for longer periods of time (months rather than days when compared to neutrophils). Monocytes illicit the immune response through phagocytosis, antigen presentation, and cytokine production each of which has a specific and deliberate function in enhancing the immune response through both protective prophylaxis and active phagocytosis. 2 spin protocols tend to greatly enhance monocyte concentrations, up to 7 times baseline. This would help avoid the potential harmful inflammation incurred by large concentrations of neutrophils that go through cellular necrosis, but some studies indicate this protocol can increase a pro-inflammatory Interleukin which may still be detrimental to the overall Regenerative Response we are trying to illicit.
Therefore so called Leukocyte Rich PRP does have a higher total Platelet Number content but also, has been show to be more pro-inflammatory and more Catabolic. Whereas a Leukocyte Poor PRP has shown a more anabolic response in Cartilage and Tendon cells, with less pro-inflammatory mediators, even though there is a much lower concentration of Platelets. Fortunately in our clinic we have a in house Laboratory and Sterile Laminar Flow Hood for custom processing of PRP samples, where we can do customized Spin Protocols to control the Leukocyte/RBC and Platelet content. Automated PRP desktop/portable PRP processing systems lack the ability to adjust the PRP Composition to this level of precision.
Our PRP has less than 1% of red blood cells (RBCs). RBCs add to the PRP viscosity which increases injection difficulty and reduces injection site tissue saturation, and tends to significantly increase post injection flare. Physicians can improve the application experience for themselves and their patients by allowing smaller gauge needles. RBCs in PRP have also been attributed to increase pain and inflammation at the injection site after application.
Our PRP is non-acidic. It has a normal pH that is greater than 7.35 and less than 7.5. A normal pH further mitigates the burning pain and inflammation at the injection site after application. Most PRP preparations are acidic and require buffering prior to application. This PRP is comfortable to the patient, and easy for the physician. It requires no buffering and is applied without difficulty.
PM R. 2013 Mar;5(3):169-75. doi: 10.1016/j.pmrj.2012.12.010. Mautner K1, Colberg RE, Malanga G, Borg-Stein JP, Harmon KG, Dharamsi AS, Chu S, Homer P.
To determine whether ultrasound-guided platelet-rich plasma (PRP) injections are an effective treatment for chronic tendinopathies.
A retrospective, cross-sectional survey.
Four academic sports medicine centers from across the United States.
A total of 180 men and women between the ages of 18 and 75 years who received ultrasound-guided PRP injections for tendinopathy refractory to conventional treatments.
Survey on satisfaction and functional outcome.
MAIN OUTCOME MEASUREMENTS:Perceived improvement in symptoms at least 6 months after treatment, perceived change in visual analog scale score, assessment of functional pain, and overall satisfaction.
On average, patients were 48 years old, had symptoms for a median of 18 months before treatment, and answered the survey on average 15 months after treatment. Overall, 82% of patients indicated moderate to complete improvement in symptoms. The most common injection sites were the lateral epicondyle, Achilles, and patellar tendons. Other sites treated included the rotator cuff, hamstring, gluteus medius, and medial epicondyle, among others. Furthermore, 60% of patients received only 1 injection, 30% received 2 injections, and 10% received 3 or more injections. Patients' perceived decrease in visual analog scale score was 75%, from 7.0 ± 1.8 to 1.8 ± 2.0 (-5.2, SD 2.7, 95% confidence interval -5.65 to -4.86, P < .0001). In addition, at follow-up, 95% of patients reported having no pain at rest that disrupted their activities of daily living and 68% reported no pain during activities. A total of 85% of patients were satisfied with the procedure.
In this retrospective study, in which we evaluated administration of PRP for chronic tendinopathy, we found that the majority of patients reported a moderate (>50%) improvement in pain symptoms.
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