By Thomas G. Ciccone
Interview with Peter Pryzbylkowski, MD
Platelet-rich plasma (PRP) is a therapy in which doctors inject patients with a highly concentrated plasma solution in order to promote natural healing of damaged tissue. Although its first use dates back to the 1950s, PRP’s growing popularity in recent years has led to a serious assessment of its efficacy as an alternative to surgery.
Given the lack of randomized, controlled trials with PRP injections, some clinicians may be skeptical about the efficacy of the therapy. According to Peter Pryzbylkowski, MD, a board-certified interventional pain specialist, the therapy is oftentimes a hit-or-miss affair.1
“I have more often run into patients who want to avoid surgery, at all costs, and will do aggressive physical therapy to strengthen muscle groups to make up for the tear they have,” Dr. Pryzbylkowski told PPM. Typically, these patients are athletes, who need any alternative to surgery so they can get off the disabled list faster and who have no qualms about paying for the higher cost of the treatment.
What Is PRP?
PRP injections are often favored for their unique biologic origin. Doctors use 2 rounds of centrifugation to separate the blood taken from the patient using venipuncture2,3 to seperate the sample into visible layers consisting of PRP, platelet-poor plasma, and red blood cells.4,5
Doctors carefully maintain the PRP in a sterile environment to prevent contamination6 and, when appropriate, add a platelet activator (topical bovine thrombin and 10% calcium chloride) immediately prior to injection, Dr. Pryzbylkowski said.
PRP injections contain high concentrations of many of the growth factors naturally found in the alpha granules of blood platelets, including:
- Platelet-derived growth factor (PDGF)
- Epidermal growth factor (EGF)
- Insulin-like growth factor-1 (IGF-1)
- Connective tissue growth factor (CTGF)
- Transforming growth factor-beta 1 (TGF-β1)
- Basic fibroblast growth factor (bFGF)
- Vascular endothelial growth factor (VEGF)
Doctors believe that by introducing growth factors endogenous to the patient, it can have a stimulatory effect, optimizing the cells involved in the healing process that repair damaged connective tissues. During Dr. Pryzbylkowski’s PAINWeek presentation, he described his clinical experiences using PRP injections.
Dr. Pryzbylkowski, who currently practices with the Relievus Pain Management Group, noted that while the evidence base for PRP injections is questionable, he has found success using the treatment.
Through his clinical experience, PRP injections have been helpful for facilitating the healing process with acute injuries, chiefly orthopedic tendinopathies. While clinical successes vary across the board in terms of condition, most patients who respond well to PRP injections typically lack complicating factors like comorbid conditions, Dr. Pryzbylkowski told PPM.
When the therapy did work, the benefits were noticeable and long lasting and didn’t require additional injections. Dr. Pryzbylkowski limited a patient to 3 total injections, with each injection given 2 weeks apart, to determine if there was a sufficiently favorable response to the PRP therapy. Whether for tendinopathy, rotator cuff tears, ACL tears, or a wide range of other indications, one side effect appeared to be some acute irritation immediately following the PRP injections.
“The commonality is an acute increase in pain after an injection site irritation inflammatory response, 24 to 48 hours after the injection,” making it important to warn patients about this possible reaction prior to initiating the treatment, said Dr. Pryzbylkowski.
Concerns With PRP
There are other concerns with PRP injections. Without having FDA-approval for this treatment, there are no regulatory standards to indicate what the most beneficial platelet concentration may be, the proper rate of dosing, or the most appropriate indications for this treatment.7 Research studies have found injecting PRP can induce an overexpression of endogenous growth factor8 and whether this actually benefits tissue healing is still very much unknown.9
The treatment is also an expensive, typically uninsured, and time-consuming alternative for doctors and patients to consider. It’s also difficult to determine how viable a treatment PRP is for chronic pain conditions like discogenic low back pain. Despite some encouraging evidence,10 it may be difficult to use PRP injections, given the low vascularity in the intradiscal region.
“Another concern is the lack of adverse events reported in existing literature on PRP trials, which could be a suspicious trend suggesting some clinician bias,” Dr. Pryzbylkowski noted. Despite these concerns, PRP has become a more common tool in doctors’ armamentaria.
“The thing is you have major academic institutions, like the Rothman Institute in Philadelphia and the Hospital for Special Surgery in Manhattan, which are world-renowned orthopedic institutes, and doctors in those programs doing these injections,” said Dr. Pryzbylkowski.
The hope is that further utilization of PRP injections could lead to more retrospective and longitudinal data on the procedure, which potentially would help better determine more reliable evidence of its clinical efficacy and safety.
“For now, glucocorticoids arguably may be seen as a more viable intervention for spinal conditions,” Dr. Pryzbylkowski said.
There are many other areas of research to explore with PRP injections, including facet injections using PRP and caudal, cervical, and lumbar epidurals as well as PRP as prospective treatment options for pars defects, the sacroiliac joint, or injuries to supporting ligaments of the spine.
- Pryzbylkowski, P. (September, 2016).Platelet Rich Plasma: Hoax or Hope? Presentation at: PAINWeek 2016; September 6-10, 2016; Las Vegas, Nevada.
- Marx RE. Platelet-rich plasma (PRP). What is PRP and what is not PRP?Implant Dent. 2001;10:225-228.
- Alsousou J, Thompson M, Hulley P, et al. The biology of platelet-rich plasma and its application in trauma and orthopedic surgery: A review of the literature.J Bone Joint Surg Br. 2009;91:987-996.
- Dohan Ehrenfest DM, Rasmusson L, Albrektsson T, et al. Classification of platelet concentrates: From pure platelet-rich plasma (P-PRP) to leukocyte- and platelet-rich fibrin (L-PRF).Trends Biotechnol. 2009;27:158-167.
- Mazzocca AD, McCarthy MB, Chowaniec DM, et al. Platelet-rich plasma differs according to preparation method and human variability.J Bone Joint Surg Am. 2012;94:308-316.
- Arnoczky SP, Delos D, Rodeo SA. What is platelet-rich plasma?Oper Tech Sports Med. 2011;19:142-148.
- de Mos M, van der Windt AE, Jahr H, et al. Can platelet-rich plasma enhance tendon repair? A cell culture study.Am J Sports Med. 2008;36:1171-1178.
- Lyras DN, Kazakos K, Agrogiannis G, et al. Experimental study of tendon healing early phase: Is IGF-1 expression influenced by platelet rich plasma gel?Orthop Traumatol Surg Res. 2010;96:381-387.
- Knezevic NN, Candidio KD, Desai R, et al. Is Platelet-rich plasma a future therapy in pain management?Medical Clinics of North America. 2016;100(1):199-217.
- Levi D, Horn S, Tyszko S, et al. Intradiscal platelet-rich plasma injection for chronic discogenic low back pain: Preliminary results from a prospective trial.Pain Med. 2016;17(6):1010-1020.