PRP Injections: The In-Depth Truth You Need to Know

platelet-rich plasma injections also known as PRP have garnered significant attention for their remarkable results it's derived from your own body and uses its natural healing mechanisms to alleviate joint pain treat tendon injuries and accelerate your recovery but with so much Buzz you've got to wonder what's the real story behind this seemingly miraculous therapy can it truly deliver on its promises or is it just another passing Fad in this deep dive we'll be covering everything from how PRP works and its potential benefits to the risks costs and clinical evidence behind it all we'll discuss what you need to do to prepare for aprp injection as well as go over a sample recovery protocol for after your treatment we'll compare PRP injections to other common treatments such as cortisone and even discuss how platelet-rich plasma compares to stem cells by the end of this video you'll be equipped with all the knowledge that you need to make an informed decision about whether PRP injections are right for you hey everyone Dr Jeff Peng here let's first start with what is platelet-rich plasma PRP is an Innovative treatment that involves the use of a patient's own blood to promote healing and induce recovery in various areas of the body the process starts with a simple blood draw once collected the blood is placed in a centrifuge which spins at high speeds to separate the blood components this separation results in three main layers red blood cells at the bottom a thin layer of white blood cells and platelets in the middle called The Buffy coat and the liquid portion or plasma at the top it's the middleware rich in platelets and growth factors that we are particularly into interested in platelets are tiny cell fragments in our blood that play a crucial role in clotting and tissue repair the growth factors they release help to stimulate tissue healing tissue remodeling tissue proliferation and most importantly in controlling pain and inflammation platelet-rich plasma is considered to have a platelet concentration of at least four to six times that of Baseline values by concentrating these platelets and injecting them into a Target area PRP is believed to kick-start the body's natural healing processes all of this makes platelet-rich plasma a promising alternative to more invasive procedures like surgery with that said it's worth pointing out what PRP can accomplish and more importantly what it can't do PRP Therapy can effectively treat a variety of Orthopedic conditions including tendon injuries muscle muscle strains ligament sprains and Joint inflammation it has been particularly successful in addressing chronic tendinopathies and chronic overuse conditions such as tennis elbow golfer's elbow gluteal tendinopathy and plantar fasciitis PRP has also been extremely successful at reducing pain and symptoms related to osteoarthritis other Studies have shown that NFL football athletes treated with platelet-rich plasma for muscular injuries have a quicker return to play however it's important to point out that PRP is not stem cells we'll discuss the differences between platelet-rich plasma and Bone marrow-derived mesenchymal stem cells as well as adipose derived mesenchymal stem cells later in the video it's also essential to understand that PRP Therapy is not a magic cure-all it cannot reverse joint damage such as in osteoarthritis nor can it replace the need for surgery in cases where there is a complete Terror of the tendon or a ligament PRP Therapy is most effective when used as part of a multimodal treatment plan that includes exercise and physical therapy activity modification and other non-surgical treatments so the first thing we're going to talk about is how our platelet-rich plasma injections performed start to finish the entire process takes less than one hour with the longest part being the blood draw and the processing time the first step is the blood draw the amount of blood that is needed varies based on the target treatment area larger structures such as knees and hips typically require a higher dose of platelets and therefore needs a larger blood draw multiple treatment areas on the same day also require a larger blood draw the blood sample is then put in a special tube and placed in a centrifuge there are a number of different centrifugation techniques including single Spin and double spin protocols and most take about 15 to 30 minutes to process once the platelets are separated they are combined with a small amount of plasma to create the platelet-rich plasma solution the treatment area is then cleaned and sterilized to minimize the risk of infection a small amount of local anesthetic may be used to numb up the treatment area and reduce discomfort during the procedure once the area is prepped a physician will then inject the PRP solution under Imaging guidance into the injured area or damaged tissue I want to point out here that Imaging guidance is essential for platelet-rich plasma injections it doesn't matter how many years of experience your doctor has even the most skilled and seasoned Orthopedic providers can miss their injections and you certainly don't want to be the one that they miss to illustrate my point here is a comparison of accuracy for common injections using ultrasound guided and landmark based techniques the data speaks for itself Landmark based accuracies often range in the low to mid 60s accuracy with ultrasound guidance is almost always guaranteed the last thing you want to do is to undergo a medical procedure only for your healthcare provider to do a landmark based injection and then miss the target so the next question is are PRP injections painful all musculoskeletal injections involve the use of a needle which can cause some discomfort to minimize this I typically employ a combination of techniques first I utilize an ethyl chloride cold spray to desensitize the skin then I administer ropivicane which is a local anesthetic to numb up the area Republican is preferred over common anesthetics like lidocaine and bupivica because it has fewer cytotoxic effects and is less likely to interfere with the effectiveness of the PRP it is important to note that while we administer the numbing medicine beneath the skin and down to the Target area we do not inject it directly into the target area this precaution is taken to ensure that the local anesthetic does not interfere with the effects of the PRP joint injections are typically well tolerated and result in only mild discomfort however tendon injections can be more uncomfortable this is because most tendon treatments involve a small degree of needle tenotomy which requires inserting the needle directly into the affected tendon to mechanically disrupt or break up damaged or degenerated tissue since only a minimal amount of local anesthetic is used in this procedure the needle tenotomy can lead to increased discomfort and pain pain okay so what can you expect after a platelet-rich plasma injection for most PRP injections you are able to drive yourself home afterwards this is something that you will want to discuss with your treating provider prior to the procedure what's really important to understand is that some soreness or pain at the injection site is normal and expected many people will actually get worse before things get better this is especially true for soft tissue injections such as tendons and ligaments this is because activation of platelets and release of growth factors in the soft tissue will result in a local inflammatory reaction this entire process is self-limiting and will resolve on its own within a week with that said this local inflammatory response can be rather uncomfortable and here's the key thing you cannot take any NZ medications to help reduce the pain common medications in the NZ class of drugs include aspirin ibuprofen naproxen diclofenac and indomethacin these medications interfere with platelet function and can then blunt the effects of your PRP this study found that enzas taken after a PRP injection resulted in significantly worse outcomes when compared to no NSAIDs you'll want to avoid all these medications for at least two weeks after the injection and if you can up to six weeks post-injection so what are you supposed to do if you have some post-injection pain but you can't take NSAIDs it is perfectly acceptable to take acetaminophen or Tylenol Tylenol works by relieving pain through a different mechanism however some studies like this one do suggest that even acetaminophen can potentially affect platelet function just to a significantly less degree than NSAIDs whether This truly affects out comes is still unknown as of right now I do advise my patients that if they have discomfort after their injection they can take one or two extra strength Tylenol every eight hours to ease the pain in addition to taking Tylenol there are a few other methods to reduce post-injection pain applying heat to the affected area can really help reduce post procedural soreness I recommend doing this for 10 minutes three times a day for the first three days after the injection heat will do two main things number one it will help improve blood flow to the area which can dissipate post-injection soreness and prevent muscle and joint stiffness number two he also helps increase cell to cell signaling So in theory applying heat will increase platelet to granulation and growth factor release both of these would be very beneficial after a PRP treatment so what kind of recovery every time are we looking at after a PRP injection recovery and Rehabilitation is actually an extremely active area of research I'm going to present a general guideline which most people can use but oftentimes the post-injection rehabilitation needs to be individualized this is definitely an area where discussing with your physician or physical therapist can be beneficial so I like to break down the post PRP injection rehab protocol into three main phases the first phase is the post-injection phase and lasts from day Zero which is the day of the injection through the end of day three the goal of the first phase is to protect the site of the injection and protecting the site of injection can mean a lot of different things it can mean just taking it easy or it can mean complete immobilization PRP treatments for arthritis generally do not require strict immobilization but PRP treatments for soft tissues can be different some tendons may require non-weight-bearing with crutches or partial weight-bearing with a walking boot this is something that needs to be discussed with your treating provider for those of you who do not need immobilization I tell my patients to just take it easy in Phase One this means no exercise and nothing above light physical activity I especially want my patients to avoid any repetitive motions and to avoid heavy loading of the treated area the reason for this is we really want to allow the platelets to do their thing any type of overuse or excessive loading can negatively affect PRP outcomes we really want to spend the first three days taking it easy after phase one we move on to phase two which runs from Days 4 to 14. the goal of phase two is to discontinue any immobilization devices and then to slowly increase load around days four to seven I recommend working on gentle stretching and range of motion activities do this for a few minutes maybe two to three times a day and this is really just to work on mobility and to prevent stiffness on day 7 to 14 I like to add light stretching strengthening and cardiovascular exercises these are not meant to be intense exercises the goal here is to start putting just a little stress on the area to promote the body's natural healing mechanisms you'll want to start with simple body weight exercises and advance to light weights do the strengthening exercises three times a week as tolerated by pain gentle stretching can be done daily now in addition to the strengthening exercises I also encourage all my patients to participate in aerobic exercises such as walking or easy pedaling on a stationary bike endurance exercises can help reduce inflammatory markers that circulate in the body like cardiovascular exercise will kick-start these benefits without adding too much stress on the body starting on day seven you can do aerobic exercises daily and Advance as tolerated after day 14 we move on into phase three which spans weeks three to six the goal here is to restore as much range of motion as possible and to improve strength and endurance this is where we also try to get athletes to work on proprioception balance training and Sport specific movements you'll want to slowly add more weights and resistance every week with the goal of building muscle continue to do strengthening exercises about three times a week we also want to advance our aerobic exercises as well this can mean different things for different people and really depends on your previous Baseline activity but the goal is to at least get you doing some type of low resistance cardio such as brisk walk cycling or swimming as you get more strength some people can advance back to jogging and then running of course all of this is with the caveat that your pain is relatively well controlled if at any point your pain gets worse back off for a few days and then gradually restart typically after the six week Mark all restrictions are lifted and we want you to get back to your previous Baseline physical activity sometimes a repeat PRP treatment is recommended no big deal you would then go back to phase one after the repeat procedure how soon can you expect results after aprp injection okay so to understand when you can expect results after a PRP injection it is important to discuss the body's natural healing Cascade after an injury a complex series of events occurs to repair damage tissue issues and to restore normal physiological function this process can be divided into three overlapping phases the first phase is the inflammatory phase which begins immediately after tissue injury it involves the activation of the immune system and the initiation of an inflammatory response platelet activation plays a crucial role in this phase as various chemical mediators such as growth factors cytokines and chemokines are released the inflammatory phase typically lasts a few days and is essential for initiating the healing process the second phase is the proliferative phase this focuses on the Regeneration and repair of damaged tissues this phase overlaps with the inflammatory phase and involves processes like angiogenesis which is the formation of new blood vessels granulation tissue formation epithelialization and fibroblast media did wound contraction all of these events contribute to the formation of new tissue the duration of the proliferative phase varies lasting several days to weeks depending on the type of injury the Final Phase is the remodeling phase where newly formed tissue undergoes restructuring and maturation this phase can last for months or even years initially the collagen fibers synthesized during the proliferative phase are disorganized and weak however over time collagen is remodeled and realigned along the lines of mechanical stress this increases tissue strength and integrity this phase allows tissues to regain their strength and functionality so when PRP is introduced into soft tissues it can be viewed as simulating a new injury this triggers the inflammatory phase which explains why some patients may experience at temporary worsening of symptoms before they start to improve Additionally the healing process following PRP injections into tendons may take approximately 8 to 10 weeks before noticeable improvements begin typically patients will start to observe a clear and definite Improvement in symptoms around the three-month mark this aligns with the remodeling phase of the body's healing Cascade in contrast PRP injections into joints particularly for arthritis related conditions yield faster results most individuals will notice a significant Improvement in symptoms within the first few weeks following the treatment unlike in soft tissue injuries where tendons require time for remodeling the main goal of PRP injections into joints is to regulate the inflammatory environment within the joint platelet activation takes place within a few days after the injection triggering the release of significant quantities of growth factors this process ultimately leads to symptom Improvement most people notice a definite Improvement by four weeks of course while the information I just presented offers a general understanding of the healing process and the expected timeline for PRP treatment it's important to understand that there are many other factors that can influence the success in response of PRP injections different tendons have varying healing capacities and some tendons require longer to heal than others the Achilles tendon for example is notoriously difficult to treat with long healing times the extent and severity of tendon injuries also play a role in the outcomes of PRP treatment severe or chronic injuries may require more extensive treatment and longer recovery periods in addition the overall metabolic health of the patient can influence healing and treatment outcomes conditions such as diabetes high blood pressure and obesity can impair that body's natural healing processes and negatively affect response to PRP how many PRP injections are required for optimal results this really depends on each individual patient and the severity of the condition being treated in some cases a single PRP injection may be sufficient to promote healing and alleviate pain however for more severe or chronic conditions multiple injections may be necessary to achieve the desired outcome let's take tennis elbow for example this is a chronic repetitive stress injury that leads to degeneration of the common extensor tendons in the elbow overloading the tendon causes micro tears to accumulate within the tendon and causes the tendon fibers to become thinned out disorganized and weak multiple systematic reviews and meta-analyzes of randomized controlled trials have shown that tennis elbow responds incredibly well to platelet-rich plasma injections a single PRP injection can lead to significantly better patient reported outcomes and longer more sustainable pain relief when compared to other injections such as cortisone or Placebo in fact a single high-dose PRP injection has been shown to have equal if not better results when compared to surgery we think tendons can potentially get by with just one high dose PRP injection because the PRP is actually working to improve the biochemistry of the tendon remember tennis elbow is caused by repetitive stress and the accumulation of all this stress and pressure results in a chronically degenerated tendon PRP seems to help remodel the tendon to treat the source of the problem this is likely why we see better long-term outcomes with PRP injections when compared to other treatments of course not everyone will be successful with just one injection sometimes repeat treatment is necessary to treat persistent or lingering symptoms I usually recommend waiting for at least three months after the first injection before reassessing and deciding if a repeat injection is needed joints on the other hand are very different let's use knee osteoarthritis as an example osteoarthritis is a disease that occurs due to the loss of articular cartilage loss of cartilage results in joint space nearing and this leads to irritation stiffness and pain damage to cartilage also results in the release of toxic enzymes and proteins into the joint space this altered biochemistry leads to chronic inflammation that weakens healthy cartilage and damages the joint unfortunately there is currently no way to reverse the damage to cartilage once it's lost it cannot be regrown neither PRP nor stem cells have been shown to be able to regrow cartilage rather the goal of these treatments is to help decrease pain and improve function related to knee osteoarthritis PRP introduces a tremendous amount of growth factors and signaling molecules that can flush out the inflammatory markers inside the knee this leads to a dramatic shift in the biochemistry of the joint which results in improved symptoms multiple studies such as this one have shown that a single high-dose PRP injection can reduce pain and improve function in those with mild to moderate osteoarthritis for up to one year other Studies have shown that you would need three low-dose PRP injections to achieve the same outcome but unlike some tendon problems where PRP can potentially solve the root cause the effects of PRP in joints will eventually wear off and when that happens symptoms will return this is because osteoarthritis is a chronic progressive disease and tends to get worse over time age genetics obesity metabolic Health prior injury all of these are risk factors for predicting worsening progression of arthritis this study performs synovial fluid analyzes and found that PRP injections resulted in significant decreases in inflammatory markers inside an arthritic knee for up to one year but at the one year time period these inflammatory markers were back to Baseline this is consistent with other studies that suggest the effects of PRP injections in joints seem to last about one year now think about this if we were to let those inflammatory markers re-accumulate in the joint the arthritis will get worse and the pain stiffness loss of function all of that will return therefore the goal of PRP treatment is to not only treat pain and symptoms but also to try to slow down the progression of arthritis this study found that one treatment series of three high-dose PRP injections slowed the progression of arthritis by up to 50 percent at five years post-treatment when compared to Placebo this data is consistent with other studies such as this one that have found that PRP injections can delay the need for knee replacement surgery with all of that said there is still a lot of debate with regards to the ideal number of PRP injection transfer joints and arthritis what's clear is that high-dose PRP is better than low-dose PRP my current treatment algorithm for arthritis is to administer one high-dose PRP injection and then re-evaluating patients in four weeks for most people they are very happy with their progress and decide to continue to work on exercise therapy some people need a second injection at the four week Mark to get them to a place they are happy with I very rarely needed to administer three high-dose PRP injections I then recommend administering booster injections at one year intervals to prevent the buildup of inflammatory markers the goal with these maintenance injections is to try to keep the joint as healthy as possible and to try to slow down the progression of arthritis I want to point out that all of this is still very Dynamic and continues to be an active area of research protocols continue to change often so this is something you want to discuss with your health care provider to individualize treatment what are the risks and side effects of PRP the beauty behind platelet-rich plasma is that because it is derived from your own body's cellular mechanisms there are no side effects from the injection the caveat is that anytime we stick anything through this skin there is a risk of bleeding and a risk of infection but these risks are minimal especially since the procedure is done with sterile technique and under ultrasound guidance in addition there is pretty much zero risk for allergic reaction that can be seen with other injectable medications again the only thing being injected are your own cells by far the biggest side effect of PRP is the post-inflammatory reaction that some people will get a few days after the injection this is especially true for soft tissue treatment for tendons without fail this always seemed to surprise my patients with how uncomfortable it can get but the bright side is it will get better on its own after a few days PRP Therapy can and should be combined with other treatments as part of a comprehensive treatment plan for various Orthopedic conditions in many cases PRP Therapy is used in conjunction with physical therapy activity modify vacation and other conservative measures to maximize the healing potential and improve patient outcomes let's first discuss combining different injections with platelet-rich plasma the first and most common question that I get is combining platelet-rich plasma with cortisone the theory is cortisone Works fast PRP works over time can we combine the two so we can get something that works fast and something that works slower but more effective over time unfortunately this does not work in practice when used together cortisone can interfere with the effectiveness of PRP injections by inhibiting the production of growth factors and cytokines this reduces the effectiveness of PRP in promoting tissue healing and regeneration in fact I recommend waiting at least four weeks after a cortisone injection before getting a PRP injection to make sure that the effects of the steroids do not affect the outcomes of platelet-rich plasma the converse is also true I recommend waiting at least four weeks after a PRP injection before administering cortisone injections in other parts of the body to ensure that the effects of the PRP are not inhibited okay so cortisone is a no-go what about how uranic acid injections can we combine that with platelet-rich plasma both ha injections and PRP injections are great treatment options for knee arthritis multiple head-to-head trials comparing PRP injections to hyaluronic acid injections suggest that people who get PRP injections have more favorable outcomes more recently there is a trend towards combining the two injections together with the hopes of achieving a synergistic effect the thought process behind this is that PRP has mainly a biological effect in treating the micro environment of an arthritic knee hyaluronic acid has more of a mechanical effect in lubricating the knee PRP and hyaluronic acid both have anti-inflammatory properties that occur through different Pathways so theoretically combining these two treatment options will result in better outcomes but in reality systematic reviews and meta-analyzes suggest that combination of PRP with hyaluronic acid is not Superior to PRP monotherapy this is true for both knee osteoarthritis as well as hip osteoarthritis there are all sorts of other cocktails that some Physicians advertise for example PRP plus bone marrow aspirate concentrate or PRP plus adipose derived mesenchymal stem cells PRP plus dextrose Prolotherapy PRP plus amniotic tissue allograft PRP plus exosomes unfortunately there just isn't a lot of evidence out there to look at all these combination Therapies in fact there just isn't a lot of data out there for some of these therapies to begin with given that PRP works really well as a solo treatment in my opinion it doesn't seem worthwhile to spend the extra money to experiment with these other treatments now I also get asked a lot if you can combine platelet-rich plasma with surgical procedures can PR be used to help augment Surgical repair of damaged tissue the answer is yes there is a growing body of evidence to support the use of augmenting Orthopedic surgeries with platelet-rich plasma for example more and more studies such as this systematic review and meta-analysis suggest that platelet-rich plasma can help augment Aid meniscus tear repair PRP augmentation led to lower failure rates as well as better post-operative pain the same is true for rotator cuff repairs both of these two studies found that platelet-rich plasma combined with a rotator cuff repair can reduce re-terror rates improve functional outcome scores and reduce overall pain how can you optimize your PRP for the best results and what do you need to do to prepare for a platelet-rich plasma injection there are many variables that can significantly affect outcomes of PRP treatments and many of these variables are things that you can control I'm going to break it down into two major categories the first is a person's overall health and Physiology and how we can try to optimize that the second is consumable such as medications or drugs and how they affect platelet function the first category is a person's overall health and Physiology and we'll start with blood pressure we all know that high blood pressure is bad it results in cardiac remodeling eventually leading to heart failure and cardiovascular disease but high blood pressure also affects platelets high blood pressure induces platelets to release their factors into the blood plasma and can decrease overall platelet numbers therefore trying to achieve optimal blood pressure control prior to aprp injection may be beneficial and improve outcomes and what about nutrition how does diet affect platelet properties well it turns out that diets high in saturated fats can negatively affect platelet function in some extreme cases we can physically see the differences most PRP preparations end up with a clear golden yellow plasma however when someone's cholesterol and triglycerides are extremely high their PRP ends up being a cloudy yellow or even milky white all of these excess fats can negatively affect PRP outcomes the same is true for blood sugar high blood glucose concentrations have been shown to activate platelets you may think this is a good thing because we want the platelets to be activated but the key thing here is we want the platelets to be activated after they are injected into their target tissue not before so if you have high blood glucose going into your PRP injection then there is a chance that many of your platelets have already been activated and quote unquote used up and if they've already been used up then you have less overall platelets that can work in the Target tissue in general you want to be eating a heart-healthy anti-inflammatory diet focus on vegetables fruits nuts seeds and fatty fish a great example of this would be the Mediterranean diet now let's move on to the second category which is drugs and consumables and we'll start with alcohol and tobacco increasing levels of alcohol consumption are associated with decreased platelet activation and aggregation as well as reduced platelet response the same is true for smoking cigarettes so trying to reduce or eliminate alcohol or tobacco consumption a few days before and after a PRP procedure May improve outcomes I also get asked a lot about cannabinoids and marijuana products whether marijuana or using topical or oral CBD affects platelet function is still still debated there are some studies to suggest that marijuana as well as CBD can interfere with platelet activation and platelet aggregation so just like tobacco and alcohol if you can avoid using cannabinoids a few days before and after your PRP injection you may get better outcomes when it comes to medications we know if you take common over-the-counter pain or anti-inflammatory medications such as aspirin ibuprofen or naproxen before or after aprp injection you will have significantly worse outcomes the reason for this is because all of these medications are in the NZ class of drugs and NSAIDs can interfere with platelet function the same is true for other anti-platelet agents such as Plavix Brilinta and effient so if you are taking these medications then the effects of the PRP will be affected other types of blood thinners are not absolute contraindications to getting AP or P injection however blood thinners like Warfarin Xarelto and Eliquis can increase your risk for bleeding this is definitely something you'll want to discuss with your health care provider with all of that said other than the mentioned types of medications pretty much every other over-the-counter or prescription medication is compatible with PRP injections common supplements including glucosamine chondroitin turmeric and curcumin boswellia Serrata fish oil and collagen are likely safe to continue with PRP injections in terms of preparing for the injection itself it's very important that you get a good night's sleep this will help promote overall well-being and make the blood draw and injection experience much more comfortable remember to drink plenty of water and stay hydrated this will make the blood draw process significantly easier with regards to food unless specifically instructed by your health care team it is generally a advisable not to skip meals prior to the procedure fasting can lead to feelings of weakness and dizziness afterwards make sure your body has adequate energy before the injection by eating a nutritious meal are there certain people who shouldn't get PRP Therapy so because platelet-rich plasma is from your own body pretty much everyone can get PRP treatments however there are a few clinical scenarios where one may want to avoid them and I'd like to briefly discuss them one such instance is when a patient has underlying cardiovascular disease such as coronary artery disease or has experienced a stroke this is because these patients are typically prescribed anti-platelet agents like aspirin or Clopidogrel we already discussed how anti-platelet agents can completely negate the effects of PRP because these medications interfere with platelet function so administering PRP injections to these patients may not be advisable as they would need to discontinue their anti-platelet medications for a few weeks this could significantly increase their risk for a major cardiovascular event in these cases the risks of stopping the anti-platelet agents far outweigh the benefits of PRP especially if there are alternative treatments another clinical scenario is if the patient has systemic inflammatory conditions such as rheumatoid arthritis or Ankylosing Spondylitis patients with these conditions often experience pain in multiple body parts and may require taking daily NSAIDs or even low-dose steroids to manage their symptoms the same is true for other people who are planning to undergo other medical procedures or surgeries these patients may need to take NSAIDs for other reasons and unfortunately that would interfere with the effects of platelet-rich plasma I also get asked a lot if age affects PRP and whether our senior athletes and Weekend Warriors can also get PRP treatments the short answer is that patients of all ages can get platelet-rich plasma when we look at the studies using PRP to treat knee osteoarthritis the mean age is in the 60s with some studies including patients who are much older all of these studies using high-dose PRP conclude that platelet-rich plasma injections have excellent outcomes in my own experience I found PRP to work well for people of all ages in general younger patients need fewer injections to achieve a desirable outcome older patients with more severe arthritis or more tendon degeneration are more likely to need more than one injection or possibly more frequent injections to achieve an equally desirable outcome our PRP injections covered by Insurance unfortunately no it is a cash pay procedure in almost all settings according to this newspaper published in early 2020 the mean cost of a PRP injection in the United States was 707 dollars with a large standard deviation of 388 dollars there were a lot of variables that affected price injections were more expensive in areas that had a higher median household income injections were also more expensive in cities that had larger population sizes geography also played a role with the West being the most expensive region in the United States the only healthcare insurance that covers PRP injections is Tricare and for those of you who don't know what Tricare is it is the healthcare insurance for the United States military active duty service members and their families and this makes total sense Tricare has a large incentive to get their active duty military members back to being healthy and Physically Active but what about all the other insurance companies Cigna Blue Cross Blue Shield Aetna United Healthcare Medicare how come these major insurances are not covering platelet-rich plasma every single one of them still considers PRP to be experimental and without sufficient evidence but in reality there is plenty of evidence that PRP injections result in better patient outcomes even major medical societies have written about the benefits of platelet-rich plasma for example the European Alliance of associations for Rheumatology put out a consensus statement with a few of the following highlights here's what they wrote number one intra-articular injections of PRP are an effective symptomatic treatment for early to moderate knee osteoarthritis number two intra-articular injections of PRP may be useful in severe knee osteoarthritis and number three PRP treatments should be offered as a second line treatment after failure of oral or non-pharmacological treatment for knee osteoarthritis this means that if oral anti-inflammatory medications like ibuprofen or naproxen or exercise and physical therapy do not help sufficiently decrease pain and symptoms the European Alliance of associations for Rheumatology recommends offering platelet-rich plasma injections for their treatment of symptomatic knee osteoarthritis and what about medical Societies in the United States the American Academy of orthopedic surgeons put out a technology overview summary on platelet-rich plasma the authors conclude that the literature supports the hypothesis that PRP can offer statistically significantly greater benefit compared to Placebo and active treatment Alternatives such as hyaluronic acid corticosteroids and NSAIDs for patient reported outcomes related to pain and symptoms for time points up to 12 months and here's what a consensus statement from the American Medical Society for sports medicine says about platelet-rich plasma they write that the research suggests that PRP injections are more effective in reducing pain and improving function than steroid or hyaluronic acid injections for knee osteoarthritis particularly in those who are younger and have mild to moderate disease when it comes to tendons they write that multiple randomized controlled trials have demonstrated that lateral epicondylopathy which is tennis elbow responds positively to PRP injections there have also been positive results seen in randomized controlled trials for the treatment of gluteus medius tendinopathy and plantar fasciopathy with PRP so with all of this data and with major medical societies confirming the efficacy and even superiority of platelet-rich plasma injections why won't insurances cover this procedure the first thing insurance companies may say is that it's too new and it has an unknown safety profile but honestly this is a non-issue the beauty of platelet-rich plasma is that it comes from your own body it is literally your own cells and you can argue that this is one of the safest procedures that you can do multiple randomized controlled trials and systematic reviews have shown that PRP is effective and safe in the long run the same cannot be said of cortisone injections cortisone injections into tendons can damage the tendons and can lead to weakened tendons and even tendon rupture cortisone injections into joints have been shown to damage healthy cartilage and increase the risk for rapidly destructive joint disease the second thing insurance companies will say is that there continue to be clinical trials showing that PRP is no better than Placebo and because of the conflicting results they refuse to cover the procedure the rebuttal to this is rather nuanced so I will again use knee osteoarthritis as an example in my opinion there is now robust data to support the use of platelet-rich plasma injections for the treatment of symptomatic knee osteoarthritis this includes randomized controlled trials systematic reviews and meta-analyzes but every once in a while we will get a clinical trial like the restore trial or the peak trial the authors from the restore trial conclude among patients with with symptomatic mild to moderate radiographic knee osteoarthritis intra-articular injection of PRP compared with injection of saline Placebo did not result in a significant difference in symptoms or joint structure at 12 months these findings do not support use of PRP for the management of knee osteoarthritis and here's what the authors from the peak trial concluded they write there is no evidence that single or multiple PRP had any additional beneficial effect compared to saline injection up to 12 months follow-up after treatment of early stage symptomatic osteoarthritis of the knee so when insurance companies glance at the conclusion of one of these studies they immediately say see doesn't work we're not going to cover PRP unfortunately many Physicians also read these studies and conclude the same thing that PRP doesn't work this article was is from the American Academy of family physicians the title is another study fails to find platelet-rich plasma injections effective for adults with degenerative joint disease of the knee here they are looking at the results from the peak trial and the title is intentionally provocative what most people don't understand and what most doctors don't understand is that not all PRP is the same dosing really matters just like for any other drug that we prescribe to patients the same thing is true for platelet-rich plasma both the restore trial and the peak trial used low-dose PRP the restore trial used a kit that produced about one to two billion platelets the peak trial used a kit that produced around two to three billion platelets it turns out newer clinical Studies have shown that there is a dose response curve for PRP just like for any other medication and you want to aim for over 10 billion platelets to get a clinical effect for knee osteoarthritis so what we actually gained from the restore and the peak trial is Clarity on the low end of the dose response curve for PRP this is also why many new studies are starting to examine the high end of the dose response curve by starting with volumes of at least 60 cc's of blood PRP dosing is now recognized to be critical in some Orthopedic journals no longer accept research papers unless the study specifically measures and publishes their PRP preparation and platelet counts okay the last thing I want to touch on is what I think will finally get insurances to cover PRP injections and of course it all comes down to money we need more studies looking at the cost benefit analysis of platelet-rich plasma injections take a look at this study they performed a cost-benefit analysis of platelet-rich plasma injections for the treatment of knee osteoarthritis for their specific country they write that intra-articular injection of PRP compared to other injections is a cost-effective treatment option for patients with mild and moderate knee osteoarthritis in addition intra-articular injection of PRP was identified as the best injection with the highest level of net monetary benefit for knee osteoarthritis management I firmly believe that if this analysis was done in other countries including in the United States we would see similar results PRP leads to better symptom Improvement and better function this allows people to be more effective at work which will generate more productivity and more revenue for their companies more importantly people are more functional and able to exercise this means they are less likely to gain weight less likely to have high blood pressure less likely to have diabetes high cholesterol or all sorts of other medical core morbidities Elderly with osteoarthritis are also more likely to exercise and this will prevent muscle atrophy this leads to reduced fracture risk and decreased costs related to hospitalizations and Elderly Care this is where PRP can have a dramatic Improvement on the quality of life and health care of our population but until these cost-benefit analyzes are done I find it unlikely that insurances will cover PRP injections how does PRP compare to other common treatments especially cortisone injections platelet-rich plasma injections have been compared to cortisone injections for a number of Orthopedic conditions rather than going through each indication one by one let's take one joint condition and one tending condition as examples let's first start with knee osteoarthritis there are now numerous randomized control trials as well as multiple systematic reviews and meta-analyzes that all conclude the same thing platelet-rich plasma injections are incredibly effective at reducing pain and symptoms as well as improving function when it comes to knee osteoarthritis all of the following studies were published in the last two years I think the evidence is clear that platelet-rich plasma injections work incredibly well for the treatment of symptomatic knee osteoarthritis but understanding why PRP works is even more important especially when compared to cortisone injections first and foremost cortisone injections really do work they last on average two to three months with some people longer and others not as long they have powerful anti-inflammatory and pain relieving effects the bigger concern is that recent studies suggest cortisone injections can damage and weaken healthy cartilage when compared to Placebo saline injections cortisone injections result in significantly more joint space nearing in the knees this by definition means worse arthritis other Studies have shown that multiple cortisone injections are associated with rapidly destructive joint disease this is characterized by rapidly Progressive joint space narrowing osteolysis and loss of the Integrity of the joint all of this can result in severe bone on bone arthritis we just don't see these side effects with platelet-rich Plasma in fact quite the opposite PRP has been shown to decrease levels of inflammatory markers inside an arthritic knee it can also reduce subchondral bone marrow edema this leads to a healthier joint environment that can protect healthy cartilage and this is what long-term data shows platelet-rich plasma injections have been shown to help protect healthy cartilage and slow down the progression of arthritis because PRP actually helps change the biochemistry of an arthritic joint it has also been shown to delay the need for knee replacement surgery okay now what about soft tissue let's look at tennis elbow and golfer's elbow these conditions are caused by repetitive stress and overloading of the tendons in the elbow The increased pressure on the tendons over time leads to micro tears in a condition known as tendinopathy the weakened tendons lead to pain and problems with function again cortisone injections for tendons have been shown to reliably reduce reduce pain and symptoms the bigger concern is that cortisone injections have side effects they restrict the delivery of nutrients to a wounded area they slow the formation of new tissue they damage existing collagen and they increase tissue degradation dermatologists and plastic surgeons actually use these catabolic effects of cortisone to break down keloids keloids are an overgrowth of collagen that lead to large Scar Tissue the big problem here is that tendons are also composed of collagen an injection of cortisone into these tendons will lead to tendon degradation and this is exactly what we see in clinical trials this study is a systematic review looking at the efficacy and safety of corticosteroid injections for the treatment of tendinopathies they write that there are consistent findings between many high quality randomized control trials that corticosterone injections reduce pain in the short term but this effect was reversed at intermediate and long terms this is a landmark meta-analysis in that it presents high level evidence that cortisone injections are harmful in the long-term treatment for tennis elbow now let's contrast all of that with platelet-rich plasma there are multiple systematic reviews and meta-analyzes that directly analyze and compare corticosteroid injections to platelet-rich plasma injections all of the following studies conclude that platelet-rich plasma injections are effective at reducing pain and symptoms in both the short term and continue to have long-term benefits in fact the authors from this review write that PRP injections may offer similar levels of improvement to pain and function when compared to tennis elbow surgery so I think it's abundantly clear that platelet-rich plasma injections are superior to corticost steroid injections in terms of improving pain and function for both joint issues as well as tendon and soft tissue problems PRP has significantly better side effect profile and may even prevent arthritis from getting worse head-to-head studies comparing platelet-rich plasma injections to hyaluronic acid injections show similar results this study was a systematic review and meta-analysis that included 14 randomized control trials comparisons showed that PRP outperforms hyaluronic acid for pain function stiffness and sports related symptoms at most follow-up time periods all the way out to one year the takeaway from all of this is that PRP has been shown to have Superior outcomes compared to other common injection therapies so we've talked about PRP versus cortisone but one of the most common questions that I get is what about stem cells what's the difference between PRP and stem cells and why can't we just regenerate our tissues when most people talk about stem cells they are thinking of pluripotent stem cells these are the cells that can divide and grow into pretty much anything think of embryos that are just starting to grow and create new organs they're incredibly versatile and can potentially regenerate or repair disease tissues and organs but when we talk about stem cell procedures or stem cell injections we're actually using and referring to another type of stem cell not the pluripotent stem cells instead we are using a special type of adult stem cell called the mesenchymal stem cell these cells have limited capacity when compared to pluripotent stem cells but they still have tremendous ability to reduce pain and symptoms so the two most common places to get mesenchymal stem cells are either from adipose or fat tissue usually harvested from the abdominal cavity this is called micro fragmented adipose tissue or mfat for short the second way to harvest mesenchymal stem cells is from the post exterior iliac crest through a procedure called a bone marrow aspiration these cells are called bone marrow aspect concentrate or bmac for short it's important to point out that once we isolate the mesenchymal stem cells and then inject them there is no current evidence to suggest that we are regrowing or regenerating anything remember these cells are not pluripotent you don't get a new knee after mesenchymal stem cell injections just like with platelet-rich plasma the goal of these stem cell treatments is to use the enormous amount of growth factors and Cascades that they initiate to help reduce pain and improve function let's first ask the question do m-fat and bmac injections really work this study looked at people with knee arthritis who were treated with mfat again that's adipose derived mesenchymal stem cells and published results at two years follow-up they found that pain improved at six months and was slightly better at 12 months but then was back to Baseline at 24 months similarly function gradually improved at 6 months and 12 months but was back to Baseline at 24 months and what about bmac this next study was a systematic review and meta-analysis that compared those who got mesenchymal stem cell injections from bmac which is bone marrow to those who got injections with mfat they found that both groups had significant improvements in pain and function more interestingly they found that the patients who got bmac had significantly better outcomes when compared to people who got emphat so it seems like both types of mesenchymal stem cell injections are effective at treating symptoms related to knee arthritis and it seems that bone marrow may be a better option than adipose tissue now we want to answer the question how do they compare with P or P this study was a two-year outcome study comparing bmac to PRP patients with knee arthritis were randomized to get either one bmac injection or one high-dose PRP injection they found that both groups had significant improvements in both pain and function at three months 6 months nine months 12 months 18 months and 24 months but what they found was that there were no differences between PRP and bmac treatment at any time point the authors conclude that PRP and bmac are both effective at treating symptoms related to knee arthritis and that bmac was not Superior to PRP so from these studies we can conclude the following both stem cell injections and PRP injections work similarly well for the treatment of knee arthritis the hypothesis that stem cells would be more effective than PRP is not currently supported by clinical trial evidence both PRP and stem cells are equally effective but here's the thing let's look at the cost both of these treatments are not covered by insurance and are cash pay only from our discussion earlier the average cost of PRP in the United States was found to be about 700 that same study reported that the average cost of stem cells was two thousand seven hundred dollars which is almost four times greater than the cost of PRP harvesting mesenchymal stem cells is also much more invasive with higher rates of adverse effects and outcomes are exactly the same until clinical trials start to show otherwise cost-benefit analyzes heavily favored PRP okay so if you are interested in pursuing PRP treatments how do you go about choosing a doctor the first thing I want to emphasize is the importance of selecting the right provider just as not all lawyers possess the same skill set and not all accountants and business managers are identical the same applies to PRP providers it is crucial to be aware that not all Healthcare professionals offering PRP are equal especially when the person promoting PRP isn't a board-certified physician while individuals such as physician assistants nurse practitioners physical therapists and even chiropractors may have good intentions they do not possess the same level of expertise when it comes to platelet-rich plasma I have encountered numerous patients who have visited their local chiropractors office and were persuaded to try umbilical or amniotic stem cells or they were told they needed a combination nation of exosomes and PRP because the two together are superior to PRP alone unfortunately many individuals are merely attempting to sell these treatments for financial gain additionally some of these providers are not even authorized to administer injections as it falls outside the scope of their practice consequently they often hire mid-level providers like a physician assistant who may lack training in administering the injections with imaging guidance resulting in a high likelihood of missing the intended target even if you do manage to find an MD or do physician it is essential to note that not all Physicians are equal many have misleading information on their websites a study investigating online direct to Consumer advertising of stem cell therapy for musculoskeletal conditions revealed that 96 of websites contain at least once statement of misinformation with an average of nearly five misleading statements per site these inaccuracies range from errors in the basic science of stem cells to outright false and deceptive claims so what steps can you take Begin by seeking out an MD or do physician ask potential providers whether they utilize Imaging guidance in their procedures inquire about platelet dosing and ask them to explain and justify the dose they plan to administer if they are unable to do so it should raise a red flag additionally ask about outcomes are they actively tracking patient outcomes or merely relying on anecdotal stories to persuade you moreover it is becoming increasingly evident that not all PRP treatments are equal there are numerous variations of platelet-rich plasma and our understanding of this field is still in its infancy many unanswered questions remain should we use leukocyte rich or leukocyte poor PRP how does platelet-rich fibrin compared to platelet-rich plasma should platelets be activated and if so what is the best activation method choosing a reputable provider who possesses extensive experience in platelet-rich plasma treatments is crucial in maximizing the potential benefits of your therapy what conditions has PRP been shown to benefit PRP injections have been extensively studied for a wide range of conditions with knee osteoarthritis elbow tendinopathies including tennis and golfer's elbow gluteal tendinopathy and plantar fasciitis being the most well-researched the robust body of evidence consists of numerous randomized control trials systematic reviews and meta-analyzes all of which provide strong support for the use of PRP injections in treating these conditions furthermore clinical trials have shown promising results for peer pre-treatment in other joints including hip osteoarthritis shoulder osteoarthritis and thumb osteoarthritis it is logical to infer that if PRP is effective for arthritis in one joint it should also yield benefits for arthritis in other joints however the evidence regarding tendons is more nuanced while PRP injections have demonstrated excellent outcomes for elbow tendon neuropathies and gluteal tendinopathies the results for conditions affecting the Achilles tendon and patellar tendons have been conflicting the variability in outcomes can be attributed to factors we previously discussed such as the use of Imaging guidance during injections and the dosage of PRP employed in clinical trials in contrast to the Achilles and patellar tendons PRP has shown efficacy in treating rotator cuff tendon pathologies including tendinopathy partial tears and impingement syndrome even adhesive capsulitis commonly known as frozen shoulder has exhibited improvement with PRP treatment hand and wrist pathologies like de quervins tenosynovitis and carpal tunnel syndrome have also responded positively to PRP Therapy even complex and challenging spine issues have found PRP to be a promising alternative to epidural steroid injections but while rich plasma treatments hold a lot of Promise in the treatment of orthopedic problems I want to reiterate that it is not a magic cure all it will not reverse arthritis it will not sew together a tendon with a full thickness tear it will not regrow a fully torn ACL as we gather more clinical trial data hopefully we can better understand what conditions can and cannot be treated with platelet-rich plasma so in order to facilitate access to this information I have compiled a medical literature database that includes randomized control trials systematic reviews and meta-analyzes on platelet-rich plasma as well as other treatments such as mesenchymal stem cells dextrose Prolotherapy hyaluronic acid corticosteroids and more each entry includes a brief summary of the findings and a link to the respective online Journal My Hope Is that this database will serve as an X excellent resource for those interested in delving deeper into the latest clinical trials involving platelet-rich plasma and related therapies I'll put a link to this database in the video descriptions so that you can check it out if you're interested in summary there is still much to be discovered about platelet-rich plasma treatments however it is evident that the effects are real and a growing body of evidence supports its efficacy PRP has been found to surpass other conventional treatment options while avoiding any Associated side effects hopefully with further research the evidence will become irrefutable leading to insurance coverage and availability for all patients lastly if you enjoyed this content please do me a favor and click the like button it will tell YouTube to spread the video to more people and help them too thanks for doing that I really appreciate it and thanks for watching

Channel: Jeffrey Peng MD

Views: 180,577

Keywords: platelet rich plasma, platelet rich plasma therapy, prp injections, platelet-rich plasma, platelet rich plasma injection, how do prp injections work, prp injection, prp therapy, stem cells, regenerative medicine, platelet rich plasma explained, platelet rich plasma injections, prp treatment, platelet-rich plasma injections, prp injection knee, arthritis treatment, platelet rich plasma injection knee, platelet rich plasma for knee arthritis

Id: zQuSVXQG9-U

Length: 69min 3sec (4143 seconds)

Published: Mon Jun 19 2023