Platelet Rich Plasma (PRP) Therapy

Arthritis and Rheumatic Disease Specialties is pleased to begin offering the use of platelet-rich plasma (PRP therapy) to the patient population who suffer from chronic musculoskeletal conditions and have failed to respond to conventional therapies. These conventional therapies include the use of non-steroidal anti-inflammatory drugs, physical therapy modalities, and intraarticular steroid injections.

While PRP therapy has been available to the public for approximately the last 12 years, it is only more recently that the literature and experience of physicians utilizing this therapy have reached a point where the acceptance of this form of therapy has begun to become part and parcel of advanced cutting-edge musculoskeletal treatment.

We at AARDS have been using this form of therapy for the last 12 months. We have developed an environment whereby we are able to administer the platelet-rich plasma in a dedicated sterile environment utilizing ultrasound guidance technique to maximize the placement of the needle which is administering the PRP therapy.

While PRP therapy has been performed by a number of different specialties, it is actually very logical for rheumatologists and associated specialists to be the specialty that has the most expertise in delivering platelet-rich plasma to areas of the joints or musculoskeletal systems that require skilled and accurate use of this technology.

Rheumatologists, by virtue of their training, are board certified in Internal Medicine and have a background that specifically includes the study and knowledge of the immune system, autoimmune disease, musculoskeletal disorders causing chronic pain, and the use of therapeutic tools to reduce pain, swelling and inflammation, and the need for surgery that is often the treatment of last resort for many patients.

The initial popularity of PRP grew as a result that it is a safe and natural alternative to surgery. PRP allows the healing process to use the body’s own natural growth factors. By harvesting the patient’s own natural platelets, one is able to create an abundance of growth factors and cytokines that can prevent inflammation from continuing or progressing. There is research that shows the platelets are very instrumental in attracting bioactive proteins through the area of inflammation to promote natural healing. The significant advantage of PRP therapy is that it is using the patient’s own natural serum. There is far less likelihood of any adverse events occurring because of a foreign body reaction, immune rejection, or progressive tissue atrophy or rupture of tendons, as is the case often seen with the current corticosteroid injections.

PRP has been shown to be very successful in a large number of patients who have failed traditional corticosteroid injections. Ideally, it should be performed under some form of either ultrasonic or fluoroscopic guidance to make sure that the needle is in the right location when the PRP is being administered.

Indications for the use of PRP therapy include tendonitis of the elbow, wrist, knee, or ankle; chronic osteoarthritis; rotator cuff injuries; muscle tears; plantar fasciitis; Achilles tendonitis; and other chronic soft tissue problems.

The number of PRP injections that will be required is entirely dependent on the site, the initial patient response, and the degree of inflammation that is in existence prior to treatment. The number of PRP injections may range from 1 to 3. These are all performed in the office in a unique environment catering specifically for this procedure.

The platelet-rich plasma is harvested in our office from the patient’s own serum. The platelets are separated from the rest of the patient’s blood by a specific technology designed to separate the platelet-rich growth-hormone-containing plasma from the rest of the patient’s serum, and this is then, under sterile conditions, injected into the specific area of complaint.

Arthritis and Rheumatic Disease Specialties has a history of innovation and providing a state-of-the-art choice of treatment to their patients with musculoskeletal disorders. In addition to the other services that we provide, the utilization of PRP therapy for our patient population is, we believe, something that allows us to provide a state-of-the-art environment for the care and healing of our patients with musculoskeletal disorders. We would like to emphasize that this treatment is not something that is guaranteed to be successful, and, at times, there is no option but to consider alternative treatments, in particular, surgery, as being more appropriate. Furthermore, standard forms of therapy which have been very successful for patients over the years are still used, in many cases prior to the consideration of PRP therapy, and in many cases are sufficient.

Not every patient is a candidate for PRP therapy, and we certainly will do our best to evaluate any patient who has a potential request for this type of therapy. We will consider and discuss the pros and cons for each individual patient when they are evaluated.

At this point in time, platelet-rich plasma is not a treatment that is covered by any of the major insurance companies, and we will work with our patients to make sure that it is affordable and available to them when needed.

For further information about PRP therapy, please go to:
Guidelines for theUse of Platelet Rich Plasma (By: The International Cellular Medical Society). We would be happy to make an appointment for any individual who is considering this therapy and hopefully, we will be able to provide you with answers to the questions which you may have.

Norman B. Gaylis, MD
NBG/swl/dbm

Epicondylitis, ACL repair helped by platelet-rich plasma

Most evidence supports the effectiveness of platelet-rich plasma therapy for elbow tendinitis and anterior cruciate ligament reconstruction, raising the possibility that insurance companies might one day cover the procedure for those problems, according to a literature review in the Journal of the American Academy of Orthopaedic Surgeons.

“The clinical evidence suggests that local injection of PRP [platelet-rich plasma] containing [white blood cells] may be beneficial to patients with chronic elbow epicondylitis refractory to standard nonsurgical treatment. However, the results of PRP treatment of other chronic tendinopathies are not as clear,” concluded lead author Dr. Wellington Hsu, an orthopedic surgeon at Northwestern University in Chicago, and his coauthors, also orthopedic surgeons. They also determined that “although no significant difference in clinical outcomes has been found, preliminary clinical evidence suggests that PRP may be beneficial during the ligamentization and maturation processes of [anterior cruciate ligament] graft healing as well as that of the patellar tendon graft harvest sites.”

However, for rotator cuff and Achilles tendon repairs, “the results of clinical studies are equivocal, and further study is needed before definitive conclusions can be drawn and recommendations can be made.” Similarly, “further study is required before conclusions can be made regarding the efficacy of PRP in the management of osteochondral lesions and knee osteoarthritis,” they wrote.

“Limited clinical evidence exists demonstrating any beneficial effects from the use of PRP in bone-healing applications. The available evidence indicates that PRP is not efficacious either alone or as an adjunct to local bone graft[s],” the authors wrote. The review included more than 60 PRP studies and publications (J. Am. Acad. Orthop. Surg. 2013;21:739-48).

PRP is created by spinning down a patient’s blood sample to isolate and concentrate platelets; the resulting solution is then injected into their joint spaces, tendon sheaths, or other areas. It’s rich in growth factors and other substances thought to aid tissue healing and regeneration.

PRP was first used in the 1950s for dermatology and oromaxillofacial conditions; “interest in PRP jumped way ahead of the research” during the last 5 years partly because celebrity athletes have been using it to recover from injuries. “The hype around PRP definitely came before the science,” which is why insurance companies don’t cover it, Dr. Hsu said in a statement.

Instead, patients sometimes pay more than $1,000 for just one of several injections during a typical treatment course. As evidence builds for some indications, “insurance companies hopefully will consider coverage,” he said.

Success varies depending on the preparation method and composition. With more than 40 commercial PRP systems on the market, both preparation method and composition vary from one study to the next, as do protocols. In addition, “the dose-response curve is not linear, and a saturation effect has been described in which an inhibitory cascade ensues once a sufficiently high concentration of platelets is reached,” the authors wrote.

“Because platelets can exert the greatest influence on healing during or immediately after the inflammatory phase of injury, some authors have postulated that the timing of the administration of PRP has a greater impact on healing than does the number of platelets,” they wrote.

Insurance coverage unlikely

Rheumatologist Norman Gaylis said he isn’t surprised by the findings; he’s had success with platelet-rich plasma at his own practice.

“We’ve seen fairly significant clinical responses in tendinitis of the elbow, Achilles tendinitis, osteoarthritis of the knee, and rotator cuff tears. We’ve seen it definitely improve symptoms and function and reduce loss of joint space in” knee osteoarthritis, he said.

Dr. Gaylis isn’t so sure, though, that insurance companies will ever cover the procedure. The large blinded trials it would take to convince them will probably never be done because there’s no way for a company to patent a natural patient-derived product like PRP.

Most people turn to PRP after failing steroid shots, NSAIDs, and other things their insurance will pay for. For those who can afford it earlier in the disease process, “we get better results,” he said.

It takes about 35-60 mL of blood to get 3-6 mL of PRP. The injection volume depends on the area treated; a knee joint might get all 6 mL. Dr. Gaylis said he injects under ultrasound guidance, and limits joint motion afterward with, for instance, an orthopedic boot.

Patients should know it can take 4-6 weeks to notice a response. After that time, Dr. Gaylis might reinject partial responders, but likely skip a second shot in nonresponders and full responders.

“We don’t use any NSAIDs immediately before or for a couple weeks after” an injection. “They may counteract the inflammatory response you are trying to generate,” he said.

Dr. Gaylis made his remarks in an interview with this newspaper. He has a private rheumatology practice in Aventura, Fla. He said he has no commercial interests in PRP outside of his own practice.

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