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Prolotherapy with Platelet Rich Plasma is a Good Alternative for
Labrum
and Menisci Degeneration and/or Tears
I can’t remember the last time a patient of ours had surgery for
a
torn meniscus or
labrum. I know I have sent a few patients for surgery in the
past, but it has been a long time.
Prolotherapy
works very well for labrum (hip and shoulder) and menisci
degeneration and tears and even more so when
platelet rich plasma (PRP)
is added. So what is PRP and how does it work?
What is PRP?
Platelets play a central role in blood clotting and wound
healing. Tissue repair begins with clot formation and platelet
degranulation, which release the
growth factors necessary
for wound repair. Platelet-derived growth factors are
biologically active substances that enhance tissue repair
mechanisms. After platelets are activated at a wound site,
proteins are released that directly and indirectly influence
virtually all aspects of the wound healing cascade. Studies have
shown a direct correlation between the platelet concentration
and the level of secretory proteins, as well as the amount of
proliferation involved in the wound healing.
In basic terms, PRP involves the application of concentrated
platelets, which release a supra-maximal quantity of growth
factors which stimulate recovery in non-healing injuries. PRP
causes a mass influx of growth factors, such as platelet-derived
growth factor, transforming growth factor and others, which
exert their effects of
fibroblasts causing proliferation
and thereby accelerating the regeneration of injured tissues.
Specifically PRP enhances the fibroblastic events involved in
tissue healing including chemotaxis, proliferation of cells,
proteosynthesis, reparation, extracellular matrix deposition,
and the remodeling of tissues. Bottom line here is that tissues
can heal faster with PRP!
How is PRP done?
The preparation of therapeutic doses of growth factors consists
of an autologous blood collection (blood from the patient),
plasma separation (blood is centrifuged), and application of the
plasma rich in growth factors (injecting the plasma into the
area.) In other words, PRP is done just like any other
Prolotherapy treatment, except the solution used for injection
is plasma enriched with growth factors from your own blood.
Typically patients are seen every 4-6 weeks like other
Prolotherapy patient. Typically two to six visits are necessary
per area.
Where is PRP used?
In the scientific literature are reports of
soft tissue injuries
treated with PRP including
tendinopathy,
tendonitis, acute and chronic
muscle strain, muscle fibrosis, ligamentous sprains and joint
capsular laxity. PRP has also been utilized to treat intra-articular
injuries. Examples include arthritis,
arthrofibrosis,
articular
cartilage
defects, meniscal injury, and chronic synovitis or
joint inflammation.
PRP has been used successfully to enhance surgical outcomes in
maxillofacial, cosmetic, spine, orthopedic, and podiatric
surgery. In regard to its use today, you will see that the
majority of doctors using it apply it onto their current
knowledge -base of Prolotherapy. In other words, the doctors
doing PRP are using it as a proliferant, much like they use
other solutions in Prolotherapy. In simple terms, PRP is a type
of Prolotherapy!
Is PRP proven? The answer to this question depends on what
condition you are talking about and who you ask. In regard to
lateral epicondylosis, according to one author, “There is strong
pilot-level evidence supporting the use of Prolotherapy,
polidocanol, autologous white blood and platelet rich plasma
injections in the treatment of lateral epicondylosis.” If you
ask Dr. Hauser, “Absolutely Prolotherapy with or without PRP
works great for lateral epicondylosis (tennis elbow/lateral
elbow pain)! This is just one example. In my experience, PRP
works great for
tendinosis, menisci or labrum degeneration or
tears, and ligament injuries not healing with other
Prolotherapy solution.
Why PRP makes sense? Ligament injury like
tendon pathology often
involves tissues with poor blood supplies. Tendon pathology has
many manifestations, for instance from spontaneous rupture to
chronic tendinitis or tendinosis (degenerated tendon); the
etiology and pathology of each are very different and poorly
understood. Tendon is a comparatively poorly vascularized tissue
that relies heavily upon synovial fluid diffusion to provide
nutrition. During tendon injury, as with damage to any tissue,
there is a requirement for cell infiltration from the blood
system to provide the necessary reparative factors for tissue
healing. Obviously if a tissue has a poor blood supply (like
tendons and ligaments) then the reparative factors necessary for
healing are likely not going to get to the injured area or not
mount a sufficient response to fully repair the tissue. Thus,
you see the need for Prolotherapy - with or without PRP! One of
the growth factors in PRP is vascular growth factor which helps
with new blood vessel formation. It could be this growth factor
and others that causes the remarkable healing with PRP.
What about using PRP in osteoarthrtic joints? If you look at the
various studies on PRP, a theoretical basis for using PRP to
effect joint pathology exists at this time. Study authors
conclude, “Intra-articular administration of PRGF (platelet rich
growth factor) might be beneficial restoring hyaluronic acid
concentrations and switching angiogenesis to a more balanced
status, but does not halt the effects of IL-1 beta on synovial
cells.”
What does this mean? Bottom line in this study - PRGF
significantly enhanced hyaluronic acid secretion compared with
platelet-poor preparations. When you see hyaluronic acid, you
have to think joint fluid. If you think more joint fluid, think
of the joint being lubricated. What would happen to a joint that
was not lubricated if it were to become more lubricated? You got
it, less stiffness, more motion, and ,of course, less pain! This
is what we have found with Prolotherapy and with Prolotherapy
and PRP.
What is really great about PRP?
Ultrasound studies before and
after PRP are showing that the tissue is healing! This is
something we knew all along with Prolotherapy, but we just had a
hard time proving it! Now that ultrasounds are showing
degenerated tendons being regenerated with Prolotherapy PRP, the
critics are being answered. Yes, it is true that Prolotherapy
stimulates the body to repair painful areas. This can be done by
injecting simple solutions such as
dextrose in the area, to more
complicated solutions using glucosamine, manganese, natural
hormones, to a person’s own growth factors through the use of
PRP.
So what are you to do? If you have pain or know of someone in
pain that you care about, then let them know that there is a
potential cure for
chronic pain and that cure is Prolotherapy!
BIBLIOGRAPHY
1. Pietrzak WS, Eppley BL. Platelet rich plasma: biology and new
technology. Journal of Craniofacial Surgery. 2005; 16:1043-1054.
2. Crane D, Everts P. Platelet Rich Plasma Matrix Grafts.
Practical Pain Management. 2008; Jan/Feb: 12-26.
3. Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma
injection grafts for musculoskeletal injuries: a review. Current
Reviews in Musculoskeletal Medicine. 2008; 3:165-174.
4. Rabago D, Best TM, Zgierska A, et al.
A systematic review of
four injection therapies for lateral epicondylosis: prolotherapy,
polidocanol, whole blood and platelet rich plasma. British
Journal of Sports Medicine. 2009
5. Sanchez A, Nurden AT, Zalduendo MM, et al. Platelet-released
growth factors enhance the secretion of hyaluronic acid and
induce hepatocyte growth factor production by synovial
fibroblasts from arthritic patients. Rheumatology.
2007;46:1769-1772.
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