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Platelet Rich Plasma (PRP)

University pain physicians (UPC) goal is to eliminate suffering and restore function for you. Regenerative medicine is a broad-based term used for elements naturally found in blood or bone marrow as derivatives of natural cells and proteins used to promote healing of connective tissue or to inhibit cytokines or degradative enzymes. (1)Platelet rich plasma, are autologous concentrations of growth factors, inflammatory mediators that have been considered to effectively repair cartilage. Growth factors within biologic therapy stimulate the fundamental building blocks of cells.

Regenerativetherapy reduces inflammation and promote soft tissue healing by recruiting inherent autologous components of bloodused to treat multiple comorbidities such as osteoarthritis, degenerative disc disease, tendinopathy, ligament strains, and tears. (2)(3) Bone marrow concentrate and platelet rich plasma (PRP) are types of regenerative therapies used by interventional pain physicians for repair of tissues. Office based injections of PRP are routinely injected into the knee with multiple studies offering concrete evidence. (4)(5)(6)(7)

The science of PRP requires a blood draw and preparation of PRP by centrifugation. Approximately 15 milliliters of your own blood is taken from your body and placed in a syringe. The blood is centrifuged to approximately 1,500 RPM for 15 minutes. The blood will then separate into two layers, one which contains platelets and a layer which contains red blood cells. The layer which contains the red blood cells is discarded and the platelet rich layer is injected into the affected area.

PRP is approved by the FDA for use of ligament grafting and approximation of bony matrices during reconstruction. These benefits are attributed to increases in growth factors, fibroblast and osteoblast activity, reduction in apoptosis and promotion of angiogenesis. PRP is often categorized into four different types; pure PRP, leukocyte rich, pure platelet-rich fibrin, leukocyte and platelet rich fibrin.

The complexity of the spinal mechanics must be broken down to components for targeted treatment therapy. Disc pathology often begins with a loss of the water content of the nucleus pulposus resulting in altered spinal biomechanics. Changes in the morphology of the discs result in compression of nerve roots, pain generators resulting directly from the disc, and chemical irritation from disc material. Intervertebral discs contain transforming growth factor alpha (TGF-a), bone morphologic proteins (BMP), growth and differentiation factor 5 (GDF5), insulin like growth factor (IL-GF). The avascular nature and the anaerobic environment of the intervertebral discs render the regenerative capacity relatively low. (8) Interventional therapies targeted to the discs should primarily focus on halting the degeneration of the disc environment and catabolic disease process of disc tissue, while stimulating regeneration. (9) Mesenchymal stem cells (MSCs) have a role in intradiscal therapy, as it has been delivered percutaneously within the nucleus pulposus. Rehydration, remodeling, and recruitment of cell nutrients comprise of mechanisms to reverse and decelerate the degenerative process. The proposed mechanisms of injecting MSCs intradiscally is the differentiation of cells to nucleus pulposus or annulus fibrosus tissue. Bone marrow-MSCs have further differentiate into glycosaminoglycans and Type II collagen. (10)(11)(12) ASIPP guidelines state that the patient may primarily help treat intervertebral disc degeneration, facet joint arthritis, and sacroiliac joint arthritis when PRP is used. (13) MSCs are more commonly used for intervertebral disc degeneration than PRP. (14)

This rationale is made on the basis that PRP contains factors that inhibit the cell matrix degrading enzymes.

The expanding frontier of regenerative medicine to treat musculoskeletal and spinal pathology are prevalent among the armamentarium of pain physicians. The American Society of Interventional Pain Physicians have created guidelines to provide safe and trustworthy standards to be used by healthcare physicians.

References:

  1. Lamb DW. The neurology of spinal pain. Phys Ther1979;59:971–973.
  2. Vina ER, Kwoh CK. Epidemiology of osteoarthritis: literature update. CurrOpinRheumatol 2018;30(2):160–7.
  3. Lane NE, Brandt K, Hawker G, et al. OARSI-FDA initiative: defining the disease state of osteoarthritis. Osteoarthritis Cartilage 2011;19(5):478–82.
  4. Samuelson EM, Ebel JA, Reynolds SB, Arnold RM, Brown DE. The Cost-Effectiveness of Platelet-Rich Plasma Compared With Hyaluronic Acid Injections for the Treatment of Knee Osteoarthritis. Arthroscopy. 2020 Jul 25:S0749-8063(20)30625-3. doi: 10.1016/j.arthro.2020.07.027. Epub ahead of print. PMID: 32721546.
  5. Chouhan DK, Dhillon MS, Patel S, Bansal T, Bhatia A, Kanwat H. Multiple Platelet-Rich Plasma Injections Versus Single Platelet-Rich Plasma Injection in Early Osteoarthritis of the Knee: An Experimental Study in a Guinea Pig Model of Early Knee Osteoarthritis. Am J Sports Med. 2019 Aug;47(10):2300-2307. doi: 10.1177/0363546519856605. Epub 2019 Jul 3. PMID: 31268737.
  6. Hepper CT, Halvorson JJ, Duncan ST, Gregory AJ, Dunn WR, Spindler KP. The efficacy and duration of intra-articular corticosteroid injection for knee osteoarthritis: a systematic review of level I studies. J Am AcadOrthop Surg. 2009 Oct;17(10):638-46. doi: 10.5435/00124635-200910000-00006. PMID: 19794221.
  7. Smith PA. Intra-articular Autologous Conditioned Plasma Injections Provide Safe and Efficacious Treatment for Knee Osteoarthritis: An FDA-Sanctioned, Randomized, Double-blind, Placebo-controlled Clinical Trial. Am J Sports Med. 2016 Apr;44(4):884-91. doi: 10.1177/0363546515624678. Epub 2016 Feb 1. PMID: 26831629.
  8. Marchand S.: The physiology of pain mechanisms: from the periphery to the brain. Rheum Dis Clin North Am 2008; 34: pp. 285-309
  9. Glyn-Jones S., Palmer A.J., Agricola R., et al: Osteoarthritis. Lancet 2015; 386: pp. 376-387
  10. Lane N.E., Brandt K., Hawker G., et al: OARSI-FDA initiative: defining the disease state of osteoarthritis. Osteoarthritis Cartilage 2011; 19: pp. 478-482
  11. Lane N.E., Shidara K., and Wise B.L.: Osteoarthritis year in review 2016: clinical. Osteoarthritis Cartilage 2017; 25: pp. 209-215
  12. Monfett M, Harrison J, Boachie-Adjei K, et al. Intradiscal platelet-rich plasma (PRP) injections for discogenic low back pain: an update. Int Orthop2016;40:1321–1328.
  13. Zeckser J, Wolff M, Tucker J, Goodwin J. Multipotent mesenchymal stem cell treatment for discogenic low back pain and disc degeneration. Stem Cells Int 2016; 2016:3908389.
  14. Wang YH, Yang B, Li WL, Li JM. Effect of the mixture of bone marrow mesenchymal stromal cells and annulus fibrosus cells in repairing the degenerative discs of rabbits. Genet Mol Res 2015; 14:2365-2373