As physical therapists, we try our best to rehabilitate our patients by working on our patients' strength, range of motion and posture. However, there are times when the patients' tissue damage is extensive that physical therapy progress plateaus. At this point, we have to consider other options and refer our patients to specialists or back to their orthopedic surgeon.
If surgery is not deemed an option, or if our patient is very adverse to the idea surgery, there are still conservative options available to attempt. One of these is PRP injections.
Platelet-Rich Plasma (PRP) injections is a form of regenerative medicine, the goal being to restore the function of tissues through tissue regeneration and repair. Physicians versed in PRP take the patients' blood and centrifuge it to separate various blood components. A portion of this centrifuged blood will be rich in platelets, which store a number of growth factors that play a critical role in the tissue healing process. The platelet rich portion (see image) is then injected into the damaged region (be it a tendon, cartilage, or disk), usually using ultrasound guidance.
Over time, PRP has anti-inflammatory effects that can reduce chronic inflammation in a joint. PRP may also stimulate the synovium in a joint to produce more hyaluronic acid, which enhances cartilage cushioning and lubrication.
Research has been mixed historically because some studies that disprove its efficacy fail to have a multidisciplinary approach to regenerative medicine, and oftentimes ignore the importance of mechanical stimulus (such as through exercise or vibration) for growth factors in to be effective on the cellular level. However, recent results are very promising when PRP injections are combined with physical therapy in helping the patient return back to function, and more recent randomized control trials are showing improved return to sports for patients who have chronic and moderate tissue damage. (see journal articles below) More and more evidence is being collected every month, and it looks hopeful that the therapy can be covered by insurance in the future. Evidence compiled for this article include successful results for 1 year post-therapy with patients who have knee osteoarthritis, and another supporting its use in acute muscle tears and return to sports.
In order to give patients a better understanding of the physician's side of administering PRP, we turn to Dr. Carl Balog MD, who happens to have a PRP clinic adjacent to Stride Strong Physical Therapy in Cedar Mill! Dr Balog is ananesthesiologist with over 20 years of experience and is the lead physician of Portland Pain and Spine. Read on about our Q&A on PRP injections:
Dr. Balog: Platelet-rich plasma (PRP) uses a patient's own concentrated platelets to augment the healing cascade. A small amount of a patient's blood is drawn and then spun at high speed. This liquid is then injected around or near the area of injury being treated. The PRP at this stage contains three to five times the concentration of growth factors compared to normal human blood. These growth factors stimulate healing. The goal is not only to relieve symptoms but to create actual healing. So when a patient has tried conservative therapies, such as rest, stretching or physical therapy, and has made little progress, they might consider PRP injections. In some cases, PRP may reduce the need for medication and/or surgery.
Which areas of the body does PRP therapy work the best on?
Dr. Balog: It has been used to treat tendon, ligament, cartilage and bone injuries, as well as arthritis. PRP is used in rotator cuff injuries/calcinosis, degenerative joint disease of the shoulder, knees, hips, tennis elbow or in plantar fasciitis, Achilles tendon and ankle ligament injuries. Recent evidence even shows significant success when injected into painful lumbar disks! PRP has been used in sports medicine for over a decade and has a very good safety profile.
Does the patient have to be healthy in order for the therapy to be effective?
Dr. Balog: We want to avoid injecting blood if there is a fever or general signs of infection. We also avoid PRP in patients on blood thinners, certain cancers, and patients whose have religious beliefs against using blood products.
Could PRP injections cause any harm to a patient?
Dr. Balog: As PRP is obtained from a patient's own blood, the risk of reaction is low. As with any injection, there is a small risk of injury to any structures in the area as well as a very small risk of infection. The use of ultrasound greatly reduces these risks.
How many doses would a patient need?
Dr. Balog: I may recommend a single injection or a series of injections based on the injury being treated and a patient's initial response to the therapy. Typically, patients respond well after two injections. I use ultrasound as a guide to placing the injection in my office. This increases the likelihood of proper PRP placement near the site of injury and the odds of success. Some patients experience mild pain and irritation of the area for several days following the injection. We ask patients to limit motion or weight-bearing activity immediately following the injection. The use of a brace, boot or cast may be recommended during the early post-injection course. Three to seven days after the injection, patients return to normal physical activities and are encouraged to continue with physical therapy.
What are the costs for PRP therapy and can insurance cover for it?
Dr. Balog: Commercial insurance does not currently cover PRP therapy. This may change in the future as more quality studies get published. In certain circumstances, such as Workers Compensation and motor vehicle accidents, PRP may be covered if prior approval is obtained. Generally speaking, the average cost per joint is between $400-600 per session, which includes follow-up and any necessary bracing. Out of pocket costs depend on the size of the joint and how many are being injected, which reflects the amount of blood being processed.
How can a patient reach you and get started with PRP therapy?
Dr. Balog: My two practice locations offer PRP injections: Portland Pain and Spine--12672 NW Barnes Road (503) 238-7246 and Nuxone--12847 NW Cornell Road (503) 372-6249. I recently opened Nuxone to allow for quick and convenient access, right next door to Stride Strong PT Cedar Mill.
- Rossi et al. Does platelet-rich plasma decrease time to return to sports in acute muscle tear? A randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2016 Apr 16.
- Raeissadat et al. Knee Osteoarthritis Injection Choices: Platelet- Rich Plasma (PRP) Versus Hyaluronic Acid (A one-year randomized clinical trial).Clin Med Insights Arthritis Musculoskelet Disord. 2015 Jan 7;8:1-8. doi: 10.4137/CMAMD.S17894. eCollection 2015.
- Kavadar G et al. Effectiveness of platelet-rich plasma in the treatment of moderate knee osteoarthritis: a randomized prospective study. J Phys Ther Sci. 2015 Dec;27(12):3863-7. doi: 10.1589/jpts.27.3863. Epub 2015 Dec 28.
- Thompson et al. Understanding Mechanobiology: Physical Therapists as a Force in Mechanotherapy and Musculoskeletal Regenerative Rehabilitation. Physical Therapy April 2016, Vol 96, No.4 pp 560-569.
- Mayo Clinic Center for Regenerative Medicine:https://mayo.edu/research/centers-programs/center-regenerative-medicine.