Platelet Rich Plasma in MSK DiseaseJason G. Attaman, DO, FAAPMR

www.jasonattaman.com | nopain@soundinterventionalpain.com | 206 395 4422

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Overview

About me

Basic Science

Applications

Image Guided PRP

Case Presentations

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Pain Medicine is an official ABMS Subspecialty

Residency in PM&R at the University of Michigan Department of Physical Medicine & Rehabilitation

Fellowship in Pain Medicine at Wayne State University Department of Anesthesiology

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Patient

Injection Psychology Medication

RIT (PRP)

Surgery Systemic Disease Excercise Sleep Manipulation

Alternative Medicine

SocialworkPT

PRP is but one tool of many!(a cool one!)

PRP Definition

• Platelet-Rich Plasma Therapy (PRP) is defined as a sample of autologous blood with concentrations of platelets in a given volume of plasma that is above the concentration found in whole blood

(Arnoczky et al, JAAOS 2010)

What is PRP therapy useful for?

Ligaments

Tendons

Joints

Discs?

Nerves?

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PRP overview

Platelets release various chemical signals when needed

These signals cause stem cells to activate, tenocytes to lay down new tendon, chondrocytes to lay down new cartilage, etc

PRP therapy accelerates this process by delivering platelets in a concentration 4-10 X normal levels.

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Works well for tendonopathy, ligament injury, hypermobility, joint degeneration, wound healing, and possibly disc healing

Ideally applied in the context of optimizing biomechanics and kinetic chain.

Used to “tighten” loose ligaments and tendons

My experience...

10-20% non responders

25% rapid responders

Majority have steady improvement in symptoms over a 6-12 week post-op period followed by a slower improvement phase

Tendon architecture improves

Overall 80% of those treated with one session have >70% long term pain relief.

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History• First introduced in the 1980s for the

treatment of cutaneous ulcers (Margolis et al, Diabetes Care 2001)

• Use expanded in the 1990s in the maxillofacial and plastic surgery fields (Marx, J Oral Maxillofac Surg 2004)

History Cont’d

• Its use in orthopedic surgery began a decade ago– Initially used with bone grafts

to augment spinal fusion and fracture healing

– Indications have expanded widely

Public Awareness• Its appeal has soared ever since Tiger Woods

and Cliff Lee swore that PRP cured them• Public awareness was raised after The New

York Times detailed the use of PRP to treat the injured Pittsburgh Stealer players Hines Ward and Troy Polamalu before the 2009 Super Bowl– The New York Times, February 17, 2009

• Blood components:– 93% RBCs– 6% platelets– 1% WBCs– Plasma (liquid component)

• PRP: – 94% platelets and plasma– 5% RBCs

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Whole Blood Vs. PRP

PRP Components

• PRP contains not only a high concentration of platelets, but also the full component of clotting factors and secretory proteins

Platelets• Important in hemostasis / clotting• Platelets are normally activated during the

inflammatory phase to begin healing• Role in the normal healing response via the

secretion of local growth factors • Growth factors released by platelets recruit

reparative cells (stem cells) and augment soft-tissue repair

(Eppley et al, Plast Reconstr Surg 2004)

Creany & Hamilton, Br J Sports Med 2008

Platelet Activation

• Platelets are stimulated to release these growth factors and cytokines by exposure either to collagen or to thrombin and calcium

PRP Preparation• “Not all PRP preparations are created equal”• PRP can be affected by:

– Variations in blood volume taken (5-120 ccs!)– Platelet recovery efficacy – Final volume of plasma in which the platelets are suspended– Presence and/or absence of RBCs and WBCs– The presence of absence of anticoagulant in the sample– The addition or absence of thrombin or calcium chloride– The addition of pH-altering compounds

(Arnoczky et al, JAAOS 2010)•

Lopez-Vidriero et al, Arthroscopy 2010

Autologous Blood Collection

Pre Centrifuge

Post Centrifuge

Withdraw PRP into procedure procedure syringe

Technique

Technique

Risks and Side Effects

Bleeding; <<1%

Infection; <<1%

No effect; <<1%

Worsening pain; <<1%

Weakness; <1%

Paralysis, death, or stroke; <<<<<<1%.

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IF image guidance employed

for injection!

Safety• No studies have documented any cases of

hyperplasia, carcinogenesis, or tumor growth

• Some systems use purified bovine thrombin to activate the platelets, which may produce coagulopathies– Most now have converted to human recombinat

thrombin

(Mei-Dan et al, Phys Sports Med 2011)

99% of MY procedures are done under image guidance to confirm needle location and increase efficacy

When image guidance is not used

Needle Tenotomy

• Several case series concluding it is effective.• McShane, J Ultra Med, 2006,2008

– ~ 60% effective• Zhu, Adv Ther, 2008

– 54% excellent outcomes• Housner, J Ultra Med, 2009

– Decrease in VAS scores at 4 and 12 weeks• Most physicians peforming PRP do not perform an aggresive

tenotomy, which in my opinion limits outcomes.– mild to no pain when local anesthetic administered

PRP & Doping

• In January of 2011, the World Anti-Doping Agency removed intramuscular PRP injections from its prohibitions

• There is a “lack of any current evidence concerning the use of these methods for purposes of performance enhancement.”– Irish Medical Times 2011

Applications• Tendinosis and tendon injuries -- Lateral epicondylitis,

Achilles tendinosis• Ligamentous injuries and reconstructive surgery -- ACL• Cartilage injuries• Osteoarthritis• Muscle injuries• Bone augmentation – fusions, nonunions• Wounds – Chronic non-healing

• ETC…

PRP & TendinopathyWhat Does The Literature Say???

Laboratory Evidence:Human Tenocytes

• de Mos et al, Am J Sports Med 2008– In-vitro study of human tenocytes treated with

PRP– Results:

• PRP stimulates tenocyte proliferation• PRP-treated tenocytes produced increased collagen

Normal Achilles Tendon

Neovascularization on Power Doppler

Laboratory Evidence: Achilles Tendon

• Virchenko & Aspenberg, Acta Orthop Scand, 2006– Rat Achilles tendon defect model– Results:

• Greater initial regeneration in a rat Achilles tendon defect treated with PRP than without

• Greater increases in tendon strength vs. controls at 14 days• Authors concluded: PRP may accelerate the initial

inflammatory phase of tendon repair, thus making cells more receptive to earlier mechanical loading

Laboratory Evidence: Achilles Tendon

• Lyras et al, Foot Ankle Int 2009– Rat Achilles tendon model investigating the

effect of PRP injection vs. saline on angiogenesis during tendon healing

– Results:• Significant increase in angiogenesis in PRP group

at 2 weeks compared to control group• Shorter healing process in the PRP group• Better organization of collagen fibers in the PRP

group

Achilles Tendon Repair• Sanchez et al, Am J Sports Med 2007

– 12 athletes s/p Achilles tendon repair– 6 patients treated with PRP at repair site– Results: PRP group demonstrated:

• Earlier functional return of ROM• Earlier return to jogging• Earlier return to training• No wound problems• Less scar tissue based upon Achilles tendon cross-

sectional area at 18 months

Achilles Tendonitis• Gaweda et al, Int J Sports Med 2010

– Prospective study on 14 patients with Achilles tendonitis (15 tendons) treated with PRP

– Results: Significant improvement in pain scores and increased tendon vascularization on ultrasound imaging

Achilles Tendinosis

• De Vos et al, Br J Sports Med 2010– Randomized, double-blind, placebo-controlled

trial of 54 patients with Achilles tendinopathy who were treated with PRP vs. control (saline injection), in addition to eccentric exercises

– Results: At 6 weeks, there was no significant improvement in tendon structure and no effect on neovascularization in the PRP group, compared to the control group

Achilles Tendinosis• O’Malley, Presented at: American

Orthopaedic Foot & Ankle Society 2010– Retrospective study of 34 patients with Achilles

tendinosis• Symptoms greater than 6 months• Failed conservative treatment

– Results:• 19 / 34 had improvement and no

longer required treatment• 5 went on to surgery

Plantar Fasciitis

• Barrett & Erredge, Podiatry Today 2004– Pilot study of 9 patients with plantar fasciitis– Used ultrasound-guided PRP injections– Results:

• 6/9 patients had complete symptom resolution after 2 months

• 77.9% of patients had complete pain resolution at 1 year

Lateral EpicondylitisHypo-echoic

Radial head

Joint space

Extensor tendon origin

Distal humerus

Lateral / Medial Epicondylitis• Mishra & Pavelko, Am J Sports Med 2006

– Prospective, nonblinded study of 20 patients who failed non-operative treatment for medial or lateral epicondylitis

– 15 patients: single PRP injection– 5 patients: single bupivicaine injection– Results in PRP group:

• 8 weeks: PRP group statistically significant improvement in VAS and Mayo Elbow Performance scores

Lateral Epicondylitis

• Mishra et al, Clin Sports Med 2009– Double-blind RCT of PRP vs. cortisone

injections of 100 patients– Results: The PRP group demonstrated greater

improvement on VAS and DASH scores at a minimum follow-up of 6 months

Lateral Epicondylitis• Peerbooms et al, AJSM 2010

– Double-blinded randomized control trial of 100 patients treated with either PRP or cortisone injection

– Results at 1 year follow-up:• VAS scores

– 73% PRP group successful vs. 49% in cortisone group• DASH scores

– 73% of PRP group successful vs. 51% in cortisone group• Cortisone group declined with time, while the PRP

group progressively improved

PRP vs Corticosteroid in LateralEpicondylitis: Netherlands Study. AJSM

Feb 2010

l Results:l VAS scores: 49% improved in steroid groupl VAS scores: 73% in the PRP group improved

l DASH: 51% in steroid group improvedl DASH: 73% in the PRP group

l PRP group kept getting better over the next year!!!l PRP patients: 64% improvement in pain, 84% disabilityl Steroid group: 24% improvement in pain, 17% disability

Patellar Tendonopathy

Evidence: Patellar Tendinopathy

• 2 animal studies showed increased strength following PRP

• Kon et al. (2009): Prospective pilot study of 20 patients with chronic patellar tendinosis (20+ months)– 70% patients improved

• Fiardo et al. (2010): Non-randomized trial, PRP/PT vs PT alone– PRP group did better

Knee Osteoarthritis

• Sanchez et al. (2008)– retrospective cohort design– PRP vs. Hyaluronan– 53% improvement in PRP vs. 10% hyaluronan

• Kon et al. (2010)– prospective cohort design– intra-articular PRP injections– significant improvement at 6 months, less at 1 year

Supraspinatus Tendonopathy

PRP and Muscle

PRP and Musclel Sanchez M, et al; “Application of Autologous Growth Factors on Skeletal Muscle Healing”, World Congress on Regenerative Medicine Podium Presentation, May

18, 2005

l Study: 20 patient prospective acute muscle injurypilot study with 6 month follow-up - Ultrasound guided

injection of PRP.l Multiple, serial prp injections at one week intervals to defect sites

after hematoma evacuationl Ultrasound demonstrated injured muscle healed fully without

fibrosis. Functional capacities 50% faster than the control group.l The athletes had full recovery in half the expected times

PRP and Muscle

l Wright-Carpenter et al 2004. IntJ of Sports Medl Pilot studyl Professional athletes with muscle strainl Administered autologous conditioned seruml Control group received actovegin/traumeell Found a reduction in recovery time in return to 100%activity in competitive sports. (16 days vs 22 days inthe control group)l MRI recovery time was accelerated as well.

PRP and Muscle

l Hammond et al. Am J Sports Med. 2009l Tib anterior of rats injected with PRP or PPP fortreatment of acute muscle strain (high repetitionmultiple small strains vs single large strain)l Conclusion: “local delivery of PRP can shorten

recovery time after a muscle strain injury in a smallanimal model.”

l Recovery of muscle from a high repetition model hasbeen shown to require myogenesis. This may explainwhy PRP was more effective in the high-repetitionprotocol.

PRP and muscle

l Cugat: unpublished case series 2005International society of arthroscopy

l 14 professional athletesl 16 muscular injuries (soccer and basketball)l PRP injected under ultrasound afterhematoma aspirationl 50% reduction in time to return to play in lesssevere injuries.l RTP diminished in each group according toseverity

Subacromial Bursagram

Glenohumeral Injection

Piriformis Myogram

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Iliopsoas bursa

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Pubic Symphisis blockfor osteitis pubis

Radiocarpal Joint Injection

Subtalar Joint

Ankle Joint

Patient Selection: who will benefit?

Who do you want to “tighten up?” aka your hypermobile patients

Any tendonopathy

Labral injuries

Facet capsule injuries

Meniscal injuries

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Rehabilitation Protocol

Ideal protocol is not yet established

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Advanced PRP

What is the pain generator?

Treatment

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Jason G. Attaman, DO, FAAPMR

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www.jasonattaman.com | nopain@soundinterventionalpain.com | 206 395 4422

Offices in Seattle, Bellevue and Auburn

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Jason G. Attaman, DO, FAAPMR

801 Pine St, Suite 100, Seattle, WA1600 116th Ave NE #202, Bellevue, WA

202 N. Division, Auburn, WA206 395 4422 phone888 688 4167 fax

nopain@soundinterventionalpain.comWWW.JASONATTAMAN.COM

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