PRP Therapy: Critical Differences

Platelet rich plasma (PRP) therapy has gained increasing attention as a non surgical option for musculoskeletal injuries. Platelets are rich in growth factors which mobilize repair cells, promote cell division and accelerate healing.  At the Centeno-Schultz Clinic  PRP has been successful in treatment of elbow, hip, knee and heel  pain( lateral and medial epicondylitis, piriformis syndrome, patellar tendinopathy and Achilles tendinopathy.

 Maximal clinical results  are obtained when  an accurate diagnosis is established, injection of PRP is performed under ultrasound guidance and a labatory prepated PRP is utilized.

 Identifying the source of pain is essential.  Delivery of the platelet concentrate must be directly into the area of damage.  Ultrasound gives direct visualization of the damaged tissue and the where the injected platelets are going.  At the Centeno-Schultz Clinic we have a state of the art laboratory which enables us to prepare a customized platelet concentrate which has a higher number of platelets and less cellular debris than bedside centrifuge units commonly employed by most clinics.

Essential Differences in PRP Therapies

Platelet rich plasma (PRP) therapy is the use of a patient’s own platelets to accelerate healing.  It is termed rich because the platelets are concentrated, typically 5-10x above the concentration that is circulating in your blood.

PRP therapy has been used for a number of different indications  including wound healing in surgery,tendinitis, cardiac care and dental health.

Platelet-rich plasma (PRP) therapy made headlines following the Super Bowl, when it was revealed that Pittsburgh Steelers Hines Ward and Troy Polamalu had undergone PRP injections in the days leading up to the game.

Are all PRP therapies the same?

NO.

There are distinct differences in platelet rich plasma .

Most PRP is created by a bedside machine that creates a platelet concentrate by spinning (centrifuge) the blood thereby separating the platelets from the other blood products.

A cell biologist in a laboratory, however,  is able to separate the platelet from other blood products and so much more.

A cell biologist can create PRP that is pure and free of any red or white blood cells.  A machine cannot.

A cell biologist can create PRP in a specific concentration for specific indications.  A machine cannot.

A cell biologist can make PRP that has a very high levels of specific, naturally occurring growth factors such as VGEF, vascular  growth endothelial factor.  A machine cannot.

At the  Centeno-Schultz Clinic we are not reliant on a machine.  Rather through the use of a state of the art lab with full-time cell biologists we are able to provide our patients with customized PRP therapies that are specifically designed for them.  This is the critical difference which translates to improved outcome.

PRP Therapy for Lumbar Disc Protrusion

The  lumbar disc is composed of two principal parts: the inner jelly(nucleus pulposis) and the outer side wall(annulus).  The annulus provides support similar to that of the side wall of your tire.  If the side wall (annulus) becomes weakened, it can bow out.  When this occurs it is referred to as a disc protrusion, herniation or extrusion depending upon how far it protrudes  outwardly.  The protruding disc can be painful itself or it can press upon a nerve root causing leg pain.

Steroid injections have been use for lumbar disc protrusions however there is concern over the side-effects of high dose steroids as  previously discussed.

PRP injections are rich in platelet derived growth factors which have the potential of  increasing blood flow and therefore healing of the disc.

 The Centeno-Schultz utilizes various types of PRP to treat lumbar disc disease.   Examples  include platelet poor plasma, plasma lysate and activated PRP.  Patient specific platelet rich plasma injections created in a state of the art lab as opposed to those created by portable centrifuge units   are just another example of how theCenteno-Schultz Clinic distinguishes itself.

Steroids: Patients Beware

Steroids are commonly used to treat pain.  Common examples include cortisone injections into knees, elbows, hips and lumbar spine.

There is increasing concern by many authors about the side-effects of steroid injections.

Hossain demonstrated that steroids were capable of shutting down normal repair and maintenance functions in the joint.(Apoptosis) 

Nakazawa demonstrated that steroids can turn off the production of catilage.

Wong identified a correlation between steroid use and bone death. (avascular necrosis of the femoral head)

At the Centeno-Schultz Clinic we too are concerned and have changed our treatment protocols from large dose steroid injections to low dose.  Most steroid injections use 6 milligrams of steroid.  At Centeno-Schultz Clinic we use a very dilute concentration of steroid which is compounded for our clinic.  A nanogram is 1/1000 th of a milligram.  Steroid injections at Centeno-Schultz Clinic  are between 50 to 100 nanograms.  This dilute solution has positive effects on joint health by increasing the concentration of growth factors and stimulating stem cell production of cartilage.

Other options for the treatment of pain include prolotherapy, PRP and stem cell therapy.

The Magic of Platelets

Platelet Rich Plasma(PRP) is commonly used to treat soft tissue injuries which include tendenopathy, tendonosis, acute and chronic muscle strain and ligamentous sprains.  PRP can also be utilized to treat intra-articular injuries such as articular cartilage defects, chronic synovitis and joint inflammation.

Hines Ward underwent PRP therapy prior the Superbowl.

PRP treated Superstar !

There are five principle growth factors present in PRP:

• TGF-β  Transforming Growth Factor
• bFGF    Basic Fibroblast Growth Factor
• PDGF   Platelet Derived Growth Factor
• EGF      Epidermal Growth Factor
• VEGF   Vascular Endothelial Growth Factor

Each factor will be examined in a separate blog.

The Centeno-Schultz Clinic has extensive experience utilizing PRP was well as other platelet derived therapies which include platelet lysate with a physiologic dose of steroid in the use of disc and leg pain.  Platelet growth factors are used to expand autologous stem cells at Regenexx.

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The Importance of Blood Supply

Blood supply to a given structure provides essential nutrients for growth, maintenance and repair.  Some structures such as the heart have a rich blood supply with multiple arteries.  Other structures have a very limited, tenuous blood supply which places them at risk for impaired growth, repair and potential cellular death. The lumbar intervertebral disc is such a structure.  While it is the cornerstone of our spine and bears the weight of our bodies as we walk, its blood supply is extremely limited.

What does this mean?  If injuries occur the lumbar disc has limited capability of repairing itself due to its very limited blood supply.  The result is a slow insidious degeneration of the lumbar disc characterized by reduction in disc height and signal.  The MRI  below on the left illustrates a degenerative L5/S1 disc.  The blue arrow identifies the spinal cord, the red arrow is pointing to the cerebral spinal fluid and the black arrow identifies the L3/4 disc.  Note the L3/4 disc has a white signal within the disc which represents hydration.  It also is identical in height and brightness to the disc above it.  Both of these discs are normal.  The white arrow identifies a degenerative L5/S1 disc which is black in color with reduction in height in comparison to the adjacent discs.

Degeneration of lumbar spine

 With injury there is also a propensity to develop bulges since the integrity of the side wall (annulus fibrosis) is compromised. 

Disc Bulge

 If sufficient damage occurs, a disc bulge can progresses to a disc herniation where an portion of  the inner contents of the disc (nucleus pulposus) are extruded.

Lumbar Disc Herniation

In a previous blog I discussed the importance of platelets and the four major growth factors they contain:   Platelet-derived growth factor (PDGF), transforming growth factor beta (TGF-b), vascular endothelial growth factor (VEGF) and epithelial growth factor (EGF). Vascular endothelial factor is responsible for angiogenesis (the creation of  new blood vessels).  These new blood vessels can provide essential nutrients to repair damaged tissue.  At Regenexx we injected concentrated VEGF adjacent a degenerative disc with the hope of improving blood flow and initiating repair.  Please see MRI results below.  On the left are MRI images of the L5/S1 disc prior to therapy.  Note there is a reduction in height and brightness of the L5/S1 disc.  On the right are MRI images of the same L5/S1 disc after therapy.  Note an increase in the height and the signal of the disc.  There is significant improvement in the disc height and signal.  What is the significance?  This is a patient who despite prior back surgery continued to have pain.  After therapy at Regenexx the patient had near complete resolution of pain as well as MRI evidence of lumbar disc repair.

Before and after therapy of L5/S1 Disc

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Platelet Rich Plasma

What do Pittsburgh Steelers’ Hines Ward and Troy Polamalu have in common?  They have both used their own blood to treat ligament and tendon injuries.  The therapy is called platelet-rich plasma (PRP) and involves the injection of concentrated platelets and plasma to the area of damage.  Instead of injecting steroids, which can lead to tissue damage and tendon rupture, physicians are now injecting a patient’s own blood products to stimulate healing.

What is PRP?  It is a concentrate of a patient’s own platelets.  In our bodies, normal platelet counts range between 150,000/μl and 350,000/μl with an average of  200,000/μl.  Animal and human studies have demonstrated that soft tissue healing enhancement only occurs when the concentration of platelets (PRP) is greater than 1,000,000/μl.  This is a concentrate of 5x the amount normally present in our bodies.

How is it made?  A small amount of a patient’s own blood is placed in a centrifuge which separates the red blood cells from the platelets.  A teaspoon of the remaining substance is injected into the damaged tissue.

How does it work?   Platelets contain several significant growth factors, which enhance tissue repair.  The most important growth factors in PRP are platelet-derived growth factor (PDGF), transforming growth factor beta (TGF-b), vascular endothelial growth factor (VEGF) and epithelial growth factor (EGF).

What are the advantages?  It is a non-surgical therapy utilizing a patient’s own cells, and therefore is not associated with allergic reaction or transmission of disease.  At the Centeno-Schultz Clinic we use PRP for repair of ligament, tendon and muscular injury.