|Year : 2015 | Volume
| Issue : 3 | Page : 121-123
Mystery of platelet rich plasma injection in painful conditions
Department of Anaesthesiology, Critical Care and Pain, RG Kar Medical College, Kolkata, West Bengal, India
|Date of Web Publication||21-Sep-2015|
Dr. Dipasri Bhattacharya
Department of Anaesthesiology, Critical Care and Pain, RG Kar Medical College, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bhattacharya D. Mystery of platelet rich plasma injection in painful conditions. Indian J Pain 2015;29:121-3
Living with chronic pain is a daily struggle and finding relief can be challenging when platelet- rich plasma (PRP) injection can open up a new horizon for treatment. PRP therapy is a new, innovative, and non-surgical approach to promote healing of injured tendons and ligaments when the conventional treatment fails. 
PRP was introduced in pain medicine since the 1990s.  Since then it is commonly used for tendinitis, muscle strain and ligamentous injury. ,, Primary use of PRP is for Lateral epicondylitis (Tennis elbow), Medial epicondylitis (Golfer's elbow), Patellar tendinitis (Jumper's knee), Achilles tendinitis More Details and Plantar fasciitis with very good result. ,
In spite of these encouraging results of platelet rich plasma (PRP) injection in different painful conditions, the controversies are there regarding issues like how to prepare PRP, what should be the dose, how many times it need to repeated, how often it need to be repeated etc.
| How PRP is made? There is no Standardization for Making Platelet Rich Plasma|| |
The PRP concentrate is made from autologous blood. After the blood is centrifuged, it separates into the serum (top coat), the platelets and white blood cells (buffy coat or middle layer), and the red blood cells (bottom layer). The middle layer contains a platelet concentration of at least 1 million platelets/uL (normal range: 150,000-350,000 platelets/uL) and a 3- to 5-fold increase in growth factor concentrations.  It takes about an hour for preparation. Using an ultrasound machine, the platelets are injected back into the patient into the damaged, painful area of the body.  The administration protocol of PRP is currently remains nonstandardized.
20 cc of blood will yield approximately 3 cc of concentrate, adequate for small target areas. But other systems use upto 60 ml of blood and prepare 6-12 ml of PRP from it. Here is no protocol based centrifuge system till date. Some PRP protocols include white blood cells, whereas others involve activation with thrombin or calcium, with variable platelet concentration. Some protocol uses single centrifugation, some uses double. The optimal concentration of platelets for PRP is also debated.  Giusti et al. examined the optimal concentration of platelets is 1.5 million platelets/uL. 
| How does PRP act?|| |
PRP enhance, proliferation, and differentiation of cells involved in tissue regeneration to promote healing.  These actions are mediated by numerous growth factors and bioactive proteins secreted by PRP's platelets following activation, in a process known as degranulation.  Still its exact mechanism of action is yet to be known. Studies have demonstrated that PRP positively affects gene expression, matrix synthesis in tendons and attenuates proinflammatory chemokines. 
| Is it a Stem Cell Theory?|| |
It is a question that is unresolved. These regenerative-capable cells are commonly referred to as mesenchymal stem cells (MSCs), or bone marrow stromal cells with the capability of replicating as undifferentiated cells.  Recent evidence by Mirsha and colleagues stated PRP may enhance the effect of MSCs. There is a statistically significant enhancement in MSC proliferation when exposed to PRP in vitro compared to controls. 
| Whether PRP has steroid like activity?|| |
PRP generally results in long-lasting relief because the degenerative tissue starts to regenerate or regrow itself. The bioactive proteins stimulate healing and repair. New research shows PRP to be more effective than steroid injections -which simply mask inflammation and have no healing capabilities. 
| Does PRP provide instant relief?|| |
It does set the stage for a cascade of healing that takes several weeks to occur. Typically, pain relief starts to occur within three to four weeks and continues to improve over a period of three to six months following an injection. The recovery time frame varies depending on what we are treating. Sometimes arthritic joints respond much faster to these injections than a patient being treated for tendonitis. ,,
| Some Factors are Still Unresolved|| |
How PRP should be prepared? What should be the actual platelet count to initiate healing process?  What should be the volume of injection? What is the speed of healing?  How it will be stored? How often it should be repeated? What is the long term side effects?
A randomized controlled trial of total 74 patients for arthroscopic repair of median to large rotator cuff tears showed that PRP therapy decreased retear rate of supraspinatus but not the speed of healing. 
Despite some unresolved factors protocol based procedure regarding preparation of PRP, injection technique, post injection advice, and concurrent use of non steroidal anti-inflammatory drugs will definitely improve the outcome.
The randomized controlled trials are still very few though PRP is being used recently for relieving pain of osteoarthritis, sacroiliac joint pain, facet joint arthropathy and refractory discogenic pain. ,,,,
Large randomized controlled trial and multicentric studies are needed in this emerging field to establish definite role of PRP, a research product of regenerative medicine with more conclusive evidence for its wide spread use in interventional medicine for chronic pain management to reduce social, psychological and economic burden of society for a pain free world.
| References|| |
de Vos RJ, Weir A, van Schie HT, Bierma-Zeinstra SM, Verhaar JA. Weinans H, et al
. Platelet-rich plasma injection for chronic Achilles tendinopathy: A randomized controlled trial. JAMA 2010;303:144-9.
Crane D, Everts P. Platelet rich plasma (PRP) matrix grafts. Pract Pain Manag 2008;8:12-26.
Topol GA, Reeves KD. Regenerative injection of elite athletes with career-altering chronic groin pain who fail conservative treatment: A consecutive case series. Am J Phys Med Rehabil 2008;87:890-902.
Marx RE. Platelet-rich plasma: Evidence to support its use. J Oral Maxillofac Surg 2004;62:489-96.
Engebretsen L, Steffen K, Alsousou J, Anitua E, Bachl N, Devilee R, et al
. IOC consensus paper on the use of platelet-rich plasma in sports medicine. Br J Sports Med 2010;44:1072-81.
Faster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: From basic science to clinical applications. Am J Sports Med 2009;37:2259-72.
Giusti I, Rughetti A, D′Ascenzo S, Millimaggi D, Pavan A, Dell′Orso L, et al
. Identification of an optimal concentration of platelet gel for promoting angiogenesis in human endothelial cells. Transfusion 2009;49:771-8.
Nguyen RT, Borg-Stein J, McInnis K. Applications of platelet-rich plasma in musculoskeletal and sports medicine: An evidence-based approach. PM R 2011;3:226-50.
Akeda K, An HS, Okuma M, Attawia M, Miyamoto K, Thonar EJ, et al
. Platelet-rich plasma stimulates porcine articular chondrocyte proliferation and matrix biosynthesis. Osteoarthritis Cartilage 2006;14:1272-80.
Kim WM, Lee HG, Jeong CW, Kim CM, Yoon MH. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med 2010;16:1285-90.
Sun Y, Feng Y, Zhang CQ, Chen SB, Cheng XG. The regenerative effect of platelet-rich plasma on healing in large osteochondral defects. Int Orthop 2010;34:589-97.
Castillo TN, Pouliot MA, Kim HJ, Dragoo JL. Comparison of growth factor and platelet concentration from commercial platelet-rich plasma separation systems. Am J Sports Med 2011;39:66-71.
Fufa D, Shealy B, Jacobson M, Kevy S, Murray MM. Activation of platelet-rich plasma using soluble type I collagen. J Oral Maxillofac Surg 2008;66:684-90.
Jo CH, Shin JS, Shin WH, Lee SY, Yoon KS, Shin S. Platelet-rich plasma for arthroscopic repair of medium to large rotator cuff tears: A randomized controlled trial. Am J Sports Med 2015;43:2102-10.
Harmon KG. Muscle injuries and PRP: What does the science say? Br J Sports Med 2010;44:616-7.
Kajikawa Y, Morihara T, Sakamoto H, Matsuda K, Oshima Y, Yoshida A, et al
. Platelet-rich plasma enhances the initial mobilization of circulation-derived cells for tendon healing. J Cell Physiol 2008;215:837-45.
Ishida K, Kuroda R, Miwa M, Tabata Y, Hokugo A, Kawamoto T, et al
. The regenerative effects of platelet-rich plasma on meniscal cells in vitro
and its in vivo
application with biodegradable gelatin hydrogel. Tissue Eng 2007;13:1103-12.
Nagae M, Ikeda T, Mikami Y, Hase H, Ozawa H, Matsuda K, et al
. Intervertebral disc regeneration using platelet-rich plasma and biodegradable gelatin hydrogel rnicrospheres. Tissue Eng 2007;13:147-58.
Hamilton B, Knez W, Eirale C, Chalabi H. Platelet enriched plasma for acute muscle injury. Acta Orthop Belg 2010;76:443-8.