An innovative, new therapy is now being used to treat pain caused by osteoarthritis and also slow

its progression. Its called Platelet Rich Plasma (PRP) and it could transform how the medical
field approaches the treatment of musculoskeletal pain.

Pain relief and healing benefits

Heres how it works. The body reacts to illness and injury with a natural healing process. Platelet
cells in the blood stream are the first to arrive on site. Packed with growth and healing factors,
platelets initiate the repair process and attract the critical assistance of stem cells. Using this
natural mechanism, PRP intensifies the bodys efforts by delivering a higher concentration of
platelets.
To create PRP, a small sample of your blood is drawn (similar to a lab test sample), and placed in
a centrifuge. This device spins the blood at high speeds, separating the platelets from the other
components. The concentrated platelet rich plasma (PRP) is then injected back into and around
the point of injury, jumpstarting and significantly strengthening your natural healing ability.

The earlier the treatment, the better the outcome

PRP can be very effective in treating osteoarthritis, especially in the earlier stages. With age, the
cartilage lining the joints can shrink and wear thin causing friction between the bones. Growths
called bone spurs and inflammation can gradually enlarge the joint leading to the pain and
dysfunction of arthritis. PRP can help reduce this inflammation and pain. It may also be able to
stimulate cartilage regeneration, which could potentially inhibit the deteriorating effects of age
and slow the progression of arthritis.

Safe, effective, lasting results

Although still in the early stages, patients treated with PRP so far have shown significant
improvements in their pain and ability to function. Not yet covered by most insurances, PRP is
an exceptionally safe procedure, performed in a sterile environment on an outpatient basis.
Because your own blood is used, there is no risk of a transmissible infection and very low risk of
allergic reaction.
The reason this new treatment can be successful and long lasting is because PRP resolves
pain through healing. Initial improvement may be seen within a few weeks, gradually
increasing as the healing progresses.
Because PRP is still relatively new and requires specialized training, the number of physicians
performing this cutting edge therapy is somewhat limited throughout the country physicians at
the National Spine & Pain Centers are currently the only providers in the Mid-Atlantic region.

How Is Platelet-Rich Plasma Made?

Injections for Knee Osteoarthritis Video

The most common way to prepare PRP involves centrifuging a patient's blood sample. A vial of blood is placed in a centrifuge, where it is spun at intensely high speeds. The spinning causes the
blood to separate into layers:

Red blood cells, approximately 45% of blood, are forced to the bottom of the vial.
White blood cells and platelets form a thin middle layer, called a buffy coat, which comprises less than 1% of the centrifuged blood.

"Platelet-poor" plasma, or plasma with a low concentration of platelets, makes up the remaining top layer, about 55% of the centrifuged blood sample.

Once the centrifuge process is complete the doctor or medical technician will remove the vial from the centrifuge and prepare the PRP solution for injection.
Centrifugation speed and time can vary. Differences in centrifugation speed and time affect the composition of PRP. There is no clear consensus on what centrifugation process produces the best
results for treating osteoarthritis.

What Is in a Platelet-Rich Plasma Injection?

Knee injection. Click to enlarge

All PRP injections are not the same. The exact make-up of platelet-rich plasma depends on several variables, including the concentration of platelets, the concentration of white blood cells, and the
use of additives.
Concentration of platelets
Normal blood has 150,000 to 450,000 platelets per microliter (L), and the concentration of platelets in platelet-rich plasma can vary from 2.5 to 9 times that.6 Concentration levels
depend on the individual's blood, how much blood was drawn, the centrifuge process (e.g., rotation speed and duration), and other clinical preparation methods.
While it may seem logical that plasma with the highest possible platelet concentration will get better results than plasma with a lower platelet concentration, that is not necessarily the
case. One lab study suggested that plasma with concentrations 2.5 times that of normal blood was ideal, and higher concentrations might actually limit new cell growth.7 More
research is needed in this area.
White blood cell count
The immune system depends on white blood cells to fight infection, but the cells' role in PRP therapy is unclear. Some experts suspect that white blood cells inhibit tissues' ability to
heal, perhaps promoting inflammation, scar tissue, and damage to nearby tissues.8 Other experts think that, while white blood cells may not aid tissue healing, they have no negative
effects, or may have beneficial effects.
As with the concentration of platelets, the concentration of white blood cells is determined by an individual's blood as well as clinical preparation methods.
Additives
Some doctors mix additives into the platelet-rich plasma. These additives, called thrombin and calcium chloride, artificially activate the platelets, stimulate clotting, and may enhance
platelet-rich plasmas regenerative properties.

Knee Osteoarthritis Treated with PRP

Researchers studying PRP and osteoarthritis often work with patients who have knee osteoarthritis, a condition that experts estimate will affect nearly half of all Americans at some point during their
lives.19 Two clinical studies that examine PRP to treat knee arthritis are described below.
1.

One study, published in 2013, involved 78 patients with osteoarthritis in both knees (156 knees).20 Each knee received one of three treatments: 1 PRP injection, 2 PRP injections, or 1
placebo saline injection. Researchers evaluated the subjects' knees 6 weeks, 3 months, and 6 months after injection. Researchers found:

Knees treated with 1 or 2 PRP injections saw a reduction in pain and stiffness as well as improvement in knee function at 6 weeks and 3 months.

At the 6-month mark positive results declined, though pain and function were still better than before PRP treatment.

The group that received placebo injections saw a small increase in pain and stiffness and a decrease in knee function.

The platelet-rich plasma used in this clinical study had 3 times the platelet concentration of normal blood and had been filtered to remove white blood cells.
2.

A second, smaller study examined patients who had experienced mild knee pain for an average of 14 months.21 Each arthritic knee underwent an MRI to evaluate joint damage and
then received a single PRP injection. Patients' knees were assessed at the 1 week, 3 month, 6 month and 1 year marks. In addition, each knee underwent a second MRI after one
year. Researchers found:
o One year after receiving a PRP injection, most patients had less pain than they did the year before (though pain had not necessarily disappeared).

MRIs showed that that the degenerative process had not progressed in the majority of knees.

While knee cartilage did not seem to regenerate for patients, the fact that the arthritis did not worsen may be significant. Evidence suggests that an average of 4 to 6% of cartilage
disappears each year in arthritic joints.22,23

PRP Does Not Work for Everyone

Not all clinical studies provide evidence that PRP alleviates osteoarthritis symptoms. In several clinical studies PRP injections were no better than a placebo treatment. Even in studies that do
provide evidence that PRP works, not all patients benefit.
PRP proponents assert that PRP fails to successfully treat symptoms in some cases because of differences in PRP formulation or injection administration - in other words, certain changes in
variables, such as PRP preparation methods, the amount of PRP injected, and the frequency of injections, can make the PRP less effective. Others suggest that PRP therapy may be a passing
fad that has limited value.24,25
It may be that PRP therapy, like other osteoarthritis treatments, works for some people but not for others, or works best in conjunction with other treatments, such as physical therapy.

Advantages of Platelet-Rich Plasma (PRP) Therapy

Osteoarthritis Video
There are several reasons why osteoarthritis patients might consider platelet-rich plasma injections:

Platelet-rich plasma is autologous, meaning it comes from the patients body, so it is natural and the injections carry few risks.
Other treatments for mild to moderate osteoarthritis can be unreliable or vary from person to person, and some have side effects or drawbacks:
o

Physical therapy and/or weight loss can often improve but not always eliminate symptoms.

Cortisone injections are proven to reduce osteoarthritis pain, but repeated injections can weaken ligaments and tendons over time, and may have a detrimental effect
on healthy cartilage. 26,27

Anti-inflammatory medications (NSAIDS) such as aspirin and ibuprofen can reduce pain, but long-term use can aggravate stomach problems, blood pressure and
heart problems.

Minor surgeries to treat osteoarthritis, such as arthroscopic debridement, have mixed results, and may be no better than placebo.28,29

Joint replacement surgeries are major surgeries that require long-term rehabilitation, and should be reserved for more debilitating cases of arthritis

Uncertainties Regarding Platelet-Rich Plasma Therapy

Knee injection. Click to enlarge

Though laboratory studies have shown platelet-rich plasma encourages cell regeneration, scientists do not completely understand how or why this happens. Experts still have many questions
regarding platelet-rich plasma treatment:

Indications, i.e. when should this treatment be used? If it is an effective treatment for osteoarthritis, should it be used in the early stages of osteoarthritis or only when all other options
are exhausted?

What are the optimal concentrations of platelets and white blood cells?

How much platelet-rich plasma should be injected?

Do certain additives, such as thrombin, make the PRP more effective?

When and with what frequency should injections be given? Is one injection enough?

What is the best rehabilitation protocol to use after PRP injection?

Several clinical trials are underway and will help add to the body of knowledge regarding platelet-rich plasma. Until more is known, doctors must answer these questions based on
the research data that are available, personal experience, and doctor-patient communication.

Before administering platelet-rich plasma injections, a doctor should also explain the:

Potential Risks
Possible benefits

Steps of the procedure

Follow-up protocol, which should include at least one follow-up appointment

Cost of the procedure

A doctor may also have the patient sign an informed consent form stating that the patient understands that platelet-rich plasma therapy is an elective procedure and that certain risks and side effects
do exist.

Cost
Intra-articular injections of platelet-rich plasma to treat osteoarthritis are considered "experimental" by most insurance companies. A single treatment of one joint can cost $400 to $2,000, paid out-ofpocket by the patient.30,31 (If more than one joint is treated, the cost increases but typically does not double.)

Contraindications for Platelet-Rich Plasma Therapy

Knee injection. Click to enlarge

Platelet-rich plasma injections may not be appropriate for osteoarthritis patients who:

Have a medical condition that could worsen or spread with injections, such as an active infection, a metastatic disease, or certain skin diseases
Have certain blood and bleeding disorders

Are undergoing anticoagulation therapy (and cannot temporarily suspend treatment)

Are anemic

Are pregnant

Additionally, patients who have an allergy to cow products should tell their doctor. These patients could experience an allergic reaction if the platelet-rich plasma is combined with an additive called
bovine thrombin, which is derived from cows.
Platelet-rich plasma injections are outpatient procedures. Because the patient's blood must be drawn and prepared for injection, a typical procedure may take anywhere from 45 to 90 minutes.

Whether the patient has a one-time injection or a series of injections spaced over weeks or months is up to the individual patient and doctor. If a series of injections is planned, a doctor may
recommend a single blood draw during the first visit and use fresh PRP in the first injection and freezing and thaw the remaining PRP as needed for future injections. However, some experts believe
freezing and thawing PRP negatively affects its usefulness and prefer to do a separate blood draw for each PRP injection.33

Platelet-Rich Plasma Injections Require Precision

An experienced physician should perform the injections. The use of imaging technology (e.g., ultrasound guidance) ensures a precise injection.
Precision is important because, like viscosupplementation treatments, platelet-rich plasma injections must be made directly into the joint capsule

Pre-Injection Precautions

Injections for Knee Osteoarthritis Video

The American Academy of Orthopaedic Surgeons recommends patients adhere to the following pre-injection guidelines:

Avoid corticosteroid medications for 2 to 3 weeks prior to the procedure

Stop taking non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, or arthritis medications such as Celebrex, a week prior to the procedure

Do not take anticoagulation medication for 5 days before the procedure

Drink plenty of fluids the day before the procedure

Some patients may require anti-anxiety medication immediately before the procedure

Although the American Academy of Orthopaedic Surgeons published these pre-injection guidelines, the organization does not advocate for or against platelet-rich plasma treatment for
osteoarthritis.34

Platelet-Rich Plasma Injections, Step-by-Step

This is an in-office procedure that involves a blood draw, preparation of the PRP, and the injection:

Blood is drawn from a vein in the patient's arm into a vial (typically 15 to 50 mL, or less than 2 ounces of blood is needed).
The blood is processed using a centrifuge machine.
A doctor or technician prepares the centrifuged platelet-rich plasma for injection.
The affected joint area is cleansed with disinfectant such as alcohol or iodine.
If ultrasound is being used, a special gel will be applied to an area of skin near the injection site. An ultrasound probe will be pressed against the gel-covered skin. A live image of the
joint will be projected onscreen for the doctor to see.
The patient is asked to relax; this will facilitate the injection and also can make the injection less painful.
Using a syringe and needle, the doctor injects a small amount (often just 3 to 6 mL) of platelet-rich plasma into the joint capsule.21
The injection area is cleansed and bandaged.

The platelet-rich plasma typically stimulates a series of biological responses, and the injection site may be swollen and painful for about 3 days.

After the PRP Injection: Immediate Follow-up Care

Patients are advised to take it easy for a few days and avoid putting strain on the affected joint.
Doctors may require or suggest that a patient:

Does not take anti-inflammatory pain medication; another pain medication may be prescribed by the doctor
Wear a brace or sling to protect and immobilize the affected joint; a patient who receives an injection at the ankle, knee, or hip may be advised to use crutches

Use a cold compress a few times a day for 10 to 20 minutes at a time to help decrease post-injection pain and swelling

See When and Why to Apply Cold to an Arthritic Joint

Patients who do not have physically demanding jobs can usually go back to work the next day. Patients can resume normal activities when swelling and pain decrease, typically a few days after the
injections. Patients should not begin taking anti-inflammatory medications until approved by the doctor.

Physical therapy
If the injection(s) is successful in reducing the patient's pain, the patient will likely be prescribed physical therapy. Doing simple exercises to build and maintain muscle strength around the affected
joint serves to decrease osteoarthritis symptoms and can slow down or halt further joint degeneration.
The most effective step toward controlling the symptoms of osteoarthritis is obtaining an early diagnosis and starting treatment as soon as possible. Non-surgical treatments are often sufficient for
the management of physical symptoms and the preservation of daily functioning.
Osteoarthritis treatment programs typically include a combination of medication and exercise therapy.

Medications

Supplements for Knee Osteoarthritis Video

Drug therapy is used to manage physical symptoms, with a focus on relieving pain and slowing progression of the disease. Some commonly used medications include:

Analgesics. Pain relievers, or analgesics, such as acetaminophen (e.g. Tylenol), or tramadol (e.g. Ultram) are used to relieve pain, but do not alleviate inflammation or swelling.
Because they have few side effects, analgesics are recommended for patients experiencing mild to moderate pain.
Topical analgesics. Topical analgesics are creams that can be applied directly to the skin over the affected area. The primary ingredients in these creams are usually counterirritants,
such as wintergreen and eucalyptus, which stimulate the nerve endings and distract the brain from joint pain. Topical analgesics are available in most drug stores, and can be used in
combination with most oral pain medications.

See Topical Pain Relief for Arthritis

NSAIDs. Non-steroidal anti-inflammatory drugs, such as aspirin, ibuprofen (e.g. Advil), naproxen (e.g. Aleve), cox-2 inhibitors) are used to reduce swelling and inflammation, and are
recommended for patients experiencing moderate to severe pain.

Physical Therapy

Physical Therapy for Knee Osteoarthritis Video

Physical therapy provides targeted exercises that help maintain the ability to perform everyday tasks such as walking, bathing, and dressing. Although rest is an important part of the healing
process, it is important to keep up with moderate levels of activity to strengthen the muscles surrounding the damaged joint. Stronger muscles provide greater stability for the joint, which in turn helps
reduce stress on the joint.
Occupational therapy may also be recommended to demonstrate appropriate modifications for everyday activities that may be causing pain.

Injections
Steroid injections are often performed if pain is moderate to severe and especially if the pain symptoms limit the patients ability to participate with exercises. When combined with physical therapy,
steroid injections can offer a very important "window of opportunity" during which the patient may more fully participate with therapy because the pain is resolved or at least better controlled. By
allowing the patient to participate with therapy, the patient may stretch and strengthen important muscles around the affected joint(s) and thereby decrease the load experienced by the joint(s) so
that the inflammation and pain do not return.

See Steroid Injections

Injections for Knee Osteoarthritis Video

Hyaluronic acid injections are another injection modality designed to help lubricate the joint and reduce the pain and inflammation of the joint. These injections attempt to help replace the joints
natural fluid and are sometimes described as "paving the pot holes in the joint." By reducing the inflammation and pain in the joint, as with steroid injections, a "window of opportunity" is opened up
for the patient to stretch and strengthen the appropriate muscles. If the patient does not use this window, then often symptoms recur in 6-12 months at which point the injections can be repeated if
necessary.

Surgery
For most patients, osteoarthritis symptoms can be successfully managed through non-surgical care. For some, however, if they are experiencing severe joint damage, extreme pain, or very
restricted mobility, surgery may be a viable option. Common types of surgery for osteoarthritis of the hip or osteoarthritis of the knee include arthroscopic surgery, osteotomy, and arthroplasty
(total joint replacement).

See Knee Surgery for Arthritis and Total Hip Replacement for Hip Arthritis

While the potential benefits of surgery, such as improved movement and pain relief, can be enticing, it is important to remember that any surgery comes with risks. These risks are higher for patients
who are overweight or have other co-morbidities, which is a concern for many osteoarthritis sufferers.

New treatment that naturally promotes long

lasting healing of musculoskeletal conditions
July 08, 2015 in Article, Low-Back Pain, Mid-Back Pain, Non-Operative Procedures, Pain
Management,
Posted by Niteesh Bharara

What is PRP (Platelet Rich Plasma)?

Platelet Rich Plasma therapy (PRP) is a ground breaking non-operative treatment option that
relieves pain by naturally promoting long lasting healing of musculoskeletal conditions. The
acronym "PRP" has most recently been featured in the news with the rising popularity of the
treatment among professional athletes, recreational athletes, and highly functional individuals.
Many have attributed PRP injections, particularly for athletic injuries, with enabling them to
return back to regular activities and competition with minimal to no pain at all. This rapidly
emerging technique shows very promising potential for many conditions such as arthritis,
tendonitis, and ligament sprains and tears.

PRP therapy presents patients with a long lasting, permanent solution through the body's natural
healing process; PRP is not something that wears off over time as with a traditional pain
injection.
The Science of PRP:

Our blood is made up of 93% red blood cells, 6% white blood cells, 1% platelets and plasma.
Platelets are best known for their function of blood-clotting to stop bleeding. Platelets, however,
are much more significant than this, as human platelets are also a critical component in injury
healing.
Platelets are naturally extremely rich in the connective tissue growth and healing factors. The
bodys first response to tissue injury is to deliver platelets to the area. Platelets initiate repair and
attract stem cells to the injury. Injecting these growth factors into damaged ligaments, tendons,
and joints stimulates the natural repair process. In order to maximize the healing process, the
platelets must be concentrated and separated from the red blood cells. The goal of PRP is to
maximize the number of platelets while minimizing the number of red blood cells in a solution
that is injected into the injured or pained area(s). In summary, PRP creates, stimulates, and
accelerates the body's natural healing process.
Which Conditions Benefit most from PRP?

PRP treatment works most effectively for chronic ligament and tendon sprains/strains that have
failed other conservative treatment, including but not limited to:

Lumbar spine disc pain

Rotator cuff injuries, including partial-thickness

Shoulder pain and instability

Tennis and golfers elbow

Hamstring and hip strains

Knee sprains and instability

Patellofemoral syndrome and patellar tendonitis

Ankle sprains

Achilles tendonitis & plantar fasciitis

Knee, hip, and other joint osteoarthritis

Nerve entrapment syndromes, such as Carpal Tunnel Syndrome

Sacroiliac (SI) joint dysfunction and pain

Lumbar and cervical facet dysfunction and pain

Additionally, PRP can be effective for many cases of osteoarthritis by stimulating healing of
cartilage and reducing pain and disability. This includes:

Knee arthritis
Hip joint arthritis

Shoulder arthritis

Ankle arthritis

Will PRP Treatment Help Me Avoid Surgery?

With any treatment option the outcome and sustained results are highly dependent on the extent
of the injury. For example in the case of mild arthritis, PRP could potentially prevent the
development of further degeneration. However, in advanced arthritic degeneration the goal of the
treatment is to minimize pain and improve function. PRP (potentially if used in tandem with the
use of stem cells) could avoid surgery such as joint replacements and potentially spinal fusion.
How is PRP Created?

Creation of PRP is simple, painless, and conveniently done at an office visit. The entire process
of drawing blood to solution preparation only takes approximately 25-30 minutes. A small
amount of blood is drawn from the patient, just like a routine blood test. Once the blood is drawn
it is then placed into a centrifuge. The centrifuge is a machine that spins the blood at high speeds
in order to separate the blood into red blood cells and concentrated platelets. Once the blood is
separated the red blood cells are discarded, and we are left with concentrated platelet rich plasma
(PRP) which is ready to be used in the treatment process.
How are the PRP Injections Administered? Are the Injections Painful?

The injection process does not take more than an hour, which includes the creation of the PRP as
explained above. The injections are performed under image guidance to assure precise placement
of the PRP. The guidance used is usually by ultrasound; however we may decide to use
fluoroscopic guidance. The number of injections varies based on each patients individualized
condition but typically range anywhere from two to six injections done over time. Patients
typically experience significant reduction in pain after the first or second injection.
Generally speaking PRP injections are not painful; however the discomfort level depends on the
part of the body being treated. Injections into the joint are of minimal discomfort. There is
sometimes a small amount of pain after the procedure; however this does not last more than a
few days and can be minimized with over the counter Tylenol. It is critical to avoid antiinflammatory medications such as Aleve, Motrin, Celebrex, Naprosyn, and Mobic.
When Can I Expect to Feel Better?

The benefit to PRP therapy is that unlike other treatments it has a sustained outcome and is
categorized as a permanent fix. The timeframe for experiencing results is dependent upon the
area of injury and the extent of the injury. On average, most patients start to see signs of
improvement in the form of reduced pain or increased function within four to six weeks.
Are There Risks with PRP?

Overall, PRP is an especially safe treatment option with no risk of allergic reaction because it is
your own blood. However, anytime a needle is placed in the body, there is a risk of infection,
bleeding, and nerve damage. These risks do not happen often, and are very rare. Other risks
depend on the area being treated. If you are unsure of the risks of your specific condition, consult
your physician.
Case Study:

Sara is a registered nurse who balances her career and active lifestyle with being a healthy role
model for her son. All of that was halted when she experienced a dislocated shoulder and an MRI
that showed a fractured timorous, torn rotator cuff, and two separate labrum tears. When sleeping
and carrying out everyday household chores became a physical burden on her she decided to
seek out alternate treatment. Sara was referred to Virginia Spine Institute for the latest nonoperative alternatives to surgery. After an initial consultation with Dr. Bharara, Sara elected
Platelet Rich Plasma to improve her condition and current state of pain.
Sara's Comments:
The day that Dr. Bharara performed my first PRP injection was the first night that I
slept through the night without waking up in excruciating pain. I saw improvement in muscles
and range of motion within a week. The next injection two months later made an even bigger
improvement. I am still a little limited in working out (no pushups yet), but I am pain free! I have
almost all of my range of motion back, and the injured shoulder is STRONGER than the
uninjured!