PRP Therapy is a concentrate of platelet-rich plasma protein derived from whole blood, centrifuged to remove red blood cells. It has a greater concentration of growth factors than whole blood and has been used to encourage a brisk healing response across several specialties, in particular, plastic surgery, dentistry, orthopedics, and dermatology.
Platelet-rich plasma (PRP) is becoming more popular as a nonoperative treatment option for a broad spectrum of medical disorders. PRP is widely used in orthopedic and sports medicine to relieve pain through the natural promotion of healing in musculoskeletal diseases such as tendonitis, arthritis, ligament sprains, and tears. In particular, PRP injections have been used for athletic injuries, resulting in exceptional healing, a rapid return to regular activities, and complete pain relief [rx].
PRP can be classified into pure – platelet-rich plasma (P-PRP), leucocyte and platelet-rich plasma (L-PRP), pure platelet-rich fibrin (P-PRF), leucocyte and platelet rich fibrin (L-PRF) based upon the technique used to prepare and the final content of the product.[rx] Serum eye drops and PRP eye drops are also available these days for ophthalmic use.[rx] PRF has been reported to be better than traditional PRP because it simulates the physiological process of platelet degranulation releasing varied growth factors.[rx,rx] Studies have also shown that leukocyte poor product is superior compared to leukocyte rich product as residual leukocytes can produce localized inflammation.[rx]
Platelet Rich Plasma PRP Therapy
PRP is produced from a person’s own blood. It is a concentration of one type of cell, known as platelets, which circulate through the blood and are critical for blood clotting. Platelets and the liquid plasma portion of the blood contain many factors that are essential for the cell recruitment, multiplication and specialization that are required for healing.
After a blood sample is obtained from a patient, the blood is put into a centrifuge, which is a tool that separates the blood into its many components. Platelet rich plasma can then be collected and treated before it is delivered to an injured area of bone or soft tissue, such as a tendon or ligament.
PRP is given to patients through an injection, and ultrasound guidance can assist in the precise placement of PRP. After the injection, a patient must avoid exercise for a short period of time before beginning a rehabilitation exercise program.
How Does Platelet Rich Plasma (PRP Therapy) Work?
Although it is not exactly clear how PRP works, laboratory studies have shown that the increased concentration of growth factors in PRP can potentially speed up the healing process.
To speed healing, the injury site is treated with the PRP preparation. This can be done in one of two ways:
PRP can be carefully injected into the injured area. For example, in Achilles tendonitis, a condition commonly seen in runners and tennis players, the heel cord can become swollen, inflamed, and painful. A mixture of PRP and local anesthetic can be injected directly into this inflamed tissue. Afterwards, the pain at the area of injection may actually increase for the first week or two, and it may be several weeks before the patient feels a beneficial effect.
PRP may also be used to improve healing after surgery for some injuries. For example, an athlete with a completely torn heel cord may require surgery to repair the tendon. Healing of the torn tendon can possibly be improved by treating the injured area with PRP during surgery. This is done by preparing the PRP in a special way that allows it to actually be stitched into torn tissues
Data suggests role for intra-articular PRP injections
In the past, anecdotes lauding the benefits of platelet-rich plasma (PRP) in the treatment of knee osteoarthritis (OA) amassed faster than we could produce empirical data. As the desire increases to use minimally invasive, cost-effective treatments prior to surgical intervention, published data is finally gaining ground. PRP has now emerged in the literature as a way to reduce OA-associated pain and morbidity in the active aging population.
At Cleveland Clinic Florida, our patients with mild-to-moderate knee OA have shown favorable clinical outcomes with ultrasound-guided intra-articular PRP injections. In total, we perform approximately 10 to 15 PRP injections per month. We have about an 80 percent success rate with an average length of pain relief of 9-12 months.
Prep method matters of Platelet Rich Plasma (PRP Therapy)
PRP is prepared by centrifuging autologous whole blood. The initial centrifugation separates the patient’s blood into three layers based on specific gravity — plasma, platelets and white blood cells, and red blood cells. Some PRP systems include a second centrifugation to further concentrate the platelets and separate the platelet-rich plasma from platelet-poor plasma. Differences among PRP systems in container size, spin time and spin rate produce PRP with varying amounts of leukocytes, RBCs and platelet concentrations. These differences can alter the efficacy of the injectate.
Hyaluronic acid or Platelet Rich Plasma (PRP)
In the past five years, at least 13 independent studies have looked specifically at PRP and knee OA, while several other recent studies have looked at the role of PRP in healing of musculoskeletal conditions in general. Of the studies on OA, 11 directly compared intra-articular PRP with intra-articular hyaluronic acid (HA). Nine studies showed better symptom scores and clinical outcomes 6 to 12 months post-treatment in the PRP groups. In the two that showed no significant difference between PRP and HA, one study used only leukocyte-rich PRP. The remaining two studies compared undefined PRP to saline, and leukocyte-poor PRP to saline, and both showed better outcomes in the PRP groups.
Bone and soft tissue injuries heal in many stages. One of the most exciting areas of research in orthopedic surgery and sports medicine involves making the most of the initial healing stages: inflammation and an increase in cells, or cell proliferation.
Platelet rich plasma (PRP) treatment is becoming a more popular option for giving a biological boost to the healing process. PRP treatment has received significant attention from the media and has been used by several of the New York Football Giants, other NFL players and elite athletes from other sports, including Tiger Woods.
How Does Platelet Rich Plasma (PRP) Help Heal The Body?
The body’s first response to soft tissue injury is to deliver platelet cells
Packed with growth and healing factors, platelets initiate repair and attract the critical assistance of stem cells
PRP’s natural healing process intensifies the body’s efforts by delivering a higher concentration of platelets directly into the area in need
To create PRP, a small sample of your blood is drawn (similar to a lab test sample) and placed in a centrifuge that spins the blood at high speeds, separating the platelets from the other components. The process is handled manually by a lab technician, producing higher concentrations of platelets and a much more pure concentration of the beneficial blood components
The PRP is then injected into and around the point of injury, jump-starting and significantly strengthening the healing process
Because your own blood is used, there is no risk of a transmissible infection and a low risk of allergic reaction
Is PRP Treatment Effective?
Several basic science studies in animal models suggest that PRP treatment can improve healing in soft tissue and bone. For example, increased numbers of cells and improved tendon strength have been noted in Achilles tendon injuries, and improved muscle regeneration has been shown in gastrocnemius (calf) muscle injuries.
These favorable findings in animal models have led to the widespread use of PRP treatment for a variety of conditions, including acute and chronic tendon problems, as well as injuries to ligaments and muscles. Some early-stage clinical studies in humans have been promising, but are limited by their study design and few patients.
The most promising early results have been seen when PRP treatment is used for chronic tendon conditions, such as lateral epicondylitis (tennis elbow) and Achilles tendinosis, which impacts the Achilles tendon. Nonetheless, a recent study in the Journal of the American Medical Association reported that there was no advantage to using PRP injection compared to saline (placebo) injection for the treatment of Achilles tendinosis.
In a small study involving knee osteoarthritis, PRP treatment was shown to be more effective than hyaluronic acid treatment. PRP has also resulted in positive or similar results when used in the treatment of rotator cuff tears and medial collateral ligament (MCL) injuries in the knee.
Overall, there is limited support of PRP treatment in published clinical studies. However, because PRP is created from a patient’s own blood, it is considered a relatively low-risk treatment with the potential to improve or speed healing.
More studies are needed to prove the effectiveness of PRP treatment and to research the best ways to standardize the treatment’s preparation.
Concerns Involving PRP Treatment
Because PRP is given in the hopes of optimizing the initial inflammatory response of healing, anti-inflammatory medications should likely be stopped at the time of PRP treatment.
Also, PRP does contain endogenous growth factors, so some agencies consider it to be a performance-enhancing substance. For instance, the World Anti-Doping Agency and the United States Anti-Doping Agency forbid the injection of PRP within muscles because of the possibility that the growth factors could enhance a person’s performance. However, there are currently no data to suggest that PRP is actually a performance-enhancing substance. Major professional sports leagues have not yet addressed the topic of PRP.
PRP offers clinical improvements
A review of the current literature suggests that patients with knee OA have a positive response to PRP treatments. Younger, more active patients with mild OA tend to have better clinical improvements with PRP when compared to older patients with more severe OA.
PRP is a minimally invasive, cost-effective procedure that has a low complication rate and a rapid recovery. Usually, patients are able to weight bear immediately postprocedure and can return to normal activities following completion of treatment.
PRP injections are performed as an outpatient procedure. Because the patient’s blood must be drawn and prepared for injection, a typical procedure may take anywhere from 45 to 90 minutes.
Platelet-Rich Plasma Injections Require Precision
An experienced physician should perform the injections. The use of imaging technology, such as ultrasound, may be used to ensure a safe and precise placement of the injection into the damaged tendon.
The American Academy of Orthopaedic Surgeons recommends patients avoid or discontinue certain medications prior to injection:
Avoid corticosteroid medications for 2 to 3 weeks prior to the procedure
Stop taking non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin (low dose, 81mg, aspirin may be permissible), or arthritis medications such as Celebrex, a week prior to the procedure
Do not take anticoagulation medication for 5 days before the procedure (done only under doctor supervision)
In addition, patients are advised to drink plenty of fluids the day before the procedure. Some patients may require anti-anxiety medication immediately before the procedure.
The American Academy of Orthopaedic Surgeons does not advocate for or against platelet-rich plasma treatment.
Platelet-Rich Plasma Injections, Step-by-Step
This is an in-office procedure that involves a blood draw, preparation of the PRP, and the injection:
Blood is drawn from a vein in the patient’s arm into a syringe (15 to 60mL, or 0.5 to 2 ounces, or more may be needed).
The blood is processed using a centrifuge machine.
A doctor or technician prepares the centrifuged platelet-rich plasma for injection.
The affected joint area is cleansed with disinfectant such as alcohol or iodine.
A lidocaine injection and/or another local anesthetic may be used to numb the injection site. However, some experts believe that anesthetics decrease the effectiveness of PRP.22
If ultrasound is being used, a special gel will be applied to an area of skin near the injection site. An ultrasound probe will be pressed against the gel-covered skin. A live image of the tendon will be projected onscreen for the doctor to see.
The patient is asked to relax; this will facilitate the injection and also can make the injection less painful.
Using a syringe and needle, the doctor injects a small amount (often just 3 to 6 mL ) of platelet-rich plasma into the affected tendon.
The platelet-rich plasma typically stimulates a series of biological responses, including inflammation, so the injection site may be swollen and painful for about 3 to 5 days.
After the PRP Injection: Immediate Follow-up Care
Platelet rich plasma injections may cause temporary inflammation, pain, and swelling. Patients are often advised to take it easy for a few days and avoid putting strain on the affected joint.
A doctor may recommend that a patient:
Avoid anti-inflammatory pain medication; the doctor may prescribe or recommend another pain medication.
Use crutches, wear a brace, and/or wear or sling to protect and immobilize the affected joint.
Apply a cold compress a few times a day for 10 to 20 minutes at a time to help decrease post-injection pain and swelling.
Treatment of PRP
Tissue repair begins with clot formation and is followed by platelet degranulation with the release of platelet growth factors. These are necessary and well-regulated processes to achieve wound healing. PRP preparations are used in gynecology for various diseases based on its known mechanisms, which involve the wound healing process and the initiation of inflammatory reactions [rx].
PRP in skin lesions and wound healing
Due to the ability of PRP to promote angiogenesis and wound healing, it is widely used in dermatology for purposes including the treatment of ulcers, scars, and alopecia. With this in mind, PRP was tested by Tehranian et al. [rx] in wound healing in high-risk women undergoing cesarean sections.
They applied PRP in 70 patients and compared them to 71 control cases without PRP application. The inclusion criteria were a body mass index (BMI) >25 kg/m2, prior cesarean section, diabetes, twin pregnancy, use of corticosteroid medication, and anemia.
Another study was conducted of 55 patients undergoing major gynecological surgery, in whom PRP was directly applied to the surgical site. The authors found that autologous platelet grafts applied in gynecological surgery were effective for pain reduction and were not associated with any adverse effects [rx].
PRP in cervical ectopy
Hua et al. [rx] conducted a randomized clinical study to compare the effectiveness of autologous PRP application to that of laser treatment for benign cervical ectopy. They applied PRP twice on the area of cervical erosion with a 1-week interval in 60 patients, while laser treatment was used in the other 60 patients.
They found that the complete cure rate was 93.7% in the PRP group and 92.4% in the laser group (p>0.05). The mean time to re-epithelialization was significantly shorter in the PRP group (p<0.01).
PRP in vulvar dystrophy
PRP has been tried in many dermatological and autoimmune conditions nonresponsive to corticosteroids, such as lichen sclerosus (LS) and eczema. LS affects the vulva and causes extensive scarring, with progressive loss of the labia minora, sealing of the clitoral hood, and burying of the clitoris.
LS also causes progressive pruritus, dyspareunia, and genital bleeding. It has a considerable impact on the quality of life of affected patients by disturbing physical activity, sexual pleasure, and causing emotional and psychological problems [rx].
This condition is treated by topical and systemic corticosteroids. Application of PRP in cases of LS resistant to steroid therapy was tried by Behnia-Willison et al. [rx] in 28 patients with LS. They injected PRP into the vulva in a fanning pattern. Patients received three PRP treatments 4 to 6 weeks apart and again at 12 months
PRP in genital fistulae
Genital fistulae are treated by many modalities, as listed by Bodner-Adler et al. [rx] in a systemic review that assessed conservative and surgical treatments. They found that small fistulae could be treated conservatively with various therapies, including PRP, with success rates ranging from 67% to 100%.
PRP has been tried in the treatment of vesicovaginal fistulae as a novel, minimally invasive approach for the closure of genital fistulae. Shirvan et al. [rx], in a series of 12 patients, injected PRP around the fistula into the tissue, and platelet-rich fibrin (PRF) glue was interpositioned in the tract.
They followed the cases for 6 months and found that 11 patients were clinically cured, with normal findings on transvaginal physical examinations and cystography. They concluded that autologous PRP injection and PRF glue interposition offered a safe, effective, and novel minimally invasive approach for the treatment of vesicovaginal fistulae that obviated the need for open surgery.
PRP in genital prolapse and urinary incontinence
Both absorbable and nonabsorbable vaginal implants used in pelvic floor reconstructive procedures have numerous serious adverse effects. PRF is a mixture of platelets, leukocytes, cytokines, and circulating stem cells that is optimal for stimulating fibroblast migration and proliferation. This mixture causes rapid remodeling and connective tissue growth after vaginal surgery [rx].
PRP in premature ovarian failure
Premature ovarian failure (POF) refers to the loss of normal function of the ovaries before age 40, accompanied by the loss of fertility. A team of researchers at Harvard University injected murine ovaries with growth factors, and mature eggs appeared to develop from ovarian stem cells. They stated that the introduction of isolated growth factor-bearing platelets directly into the ovaries might trigger a resurgence in oocyte production [rx].
PRP therapy is investigated in women with POF, infertile women more than 35 years of age, and women with low ovarian reserve. Treatment with PRP is referred to as ovarian rejuvenation; in this procedure, PRP is injected into the ovary under ultrasound guidance, similarly to ovum retrieval in in vitro fertilization (IVF). This modality of treatment is still being investigated in trials. Pantos et al. [rx]
In an animal model, 60 adult female rats were subjected to ischemia and bilateral adnexal torsion for 3 hours. Intraperitoneal PRP was administered 30 minutes prior to ischemia in one group, while the other group was not injected with PRP. Detorsion was then done, and oxidative stress levels, histopathological changes, and reperfusion injuries were lower in the PRP group than in the other group. The researchers concluded that PRP was effective for the prevention of ischemia and reperfusion damage in rat ovary [rx].
PRP in refractory endometrium
The endometrium plays an important role in achieving optimal outcomes of assisted reproductive technologies. Endometrial growth following inadequate ovarian stimulation may be insufficient, leading to poor results of IVF/ICSI cycles. Various strategies have been suggested to improve endometrial thickness, especially in resistant cases. PRP is a novel therapy that has been tried in such patients [rx].
Colombo et al. [rx] included eight patients who underwent PRP treatment. The inclusion criteria were women with more than three cancelled cryo-transfers due to poor endometrial growth (<6 mm), women with a negative hysteroscopic screening for endometrial pathology, and women with a negative bacteriologic screening. After application of PRP, the endometrial thickness was satisfactory in seven cases. A positive test for beta-human chorionic gonadotropin was found in six women.
PRP in repeated implantation failure
Repeated implantation failure (RIF) is defined as failure to conceive following several embryo transfers in IVF cycles. Numerous factors are involved in the implantation process, including embryo quality, endometrial receptivity, and immunological factors [rx].
Several methods have been suggested for RIF management, but little consensus exists on which is most effective. These methods include blastocyst transfer, assisted hatching, hysteroscopy, endometrial scratching, and immune therapy. Recently, the intrauterine infusion of PRP has been described as a way to promote endometrial growth and receptivity [rx,rx].
PRP in breast reconstruction
Many studies of PRP have been conducted in the field of aesthetic and plastic surgery, but all were pilot studies, had small samples, or used animal models. PRP together with adipose tissue has been used in breast reconstruction [rx]. Gentile et al. [rx] enrolled 100 patients aged between 19 and 60 years affected by breast soft-tissue defects. They divided the patients into two equally-sized groups.
The study group was treated with fat grafting and PRP, while the control group was treated with fat grafting injections only. They concluded that PRP mixed with fat grafts led to improvements in the maintenance of breast volume in patients affected by breast soft-tissue defects. Similar results were obtained by Salgarello et al. [rx].
PRP in female sexual dysfunction
Platelets have been found to release around 35 growth factors that promote tissue regrowth, healing, and regeneration. This fact has been utilized by aesthetic gynecologists in treatments such as vaginal rejuvenation and O-shot therapy [rx].
PRP use in sexual dysfunction is considered to be a revolutionary new nonsurgical outpatient treatment that helps improve both urinary incontinence and sexual dysfunction through using a woman’s own growth factors. The PRP is injected into specific areas of the vagina with the aid of local anesthetic cream.
This modality of treatment is called the “O-shot.” PRP immediately activates tissue regeneration, and the enhancement in sexual response is dramatic. The desired response includes improved arousal, stronger orgasm, decreased dyspareunia, and increased natural lubrication [rx].
Aesthetic practitioners have used PRP for the regeneration of vaginal mucosa, muscles, and skin. After PRP injection, vaginal vascularity is increased, with a subsequent dramatic increase in sensitivity. In addition, the skin becomes thicker and firmer, making the vagina look much more youthful. Moreover, the ligaments and muscles supporting the urethra become stronger, alleviating urinary incontinence [rx].
PRP in premature rupture of membranes
Premature rupture of membranes occurs due to damage and tears in the fetal membrane, leading to congenital infections and poor neonatal outcomes. PRP was tried in an in vitro model to evaluate the ability of PRP to seal iatrogenic fetal membrane defects. This was done using single- and double-layer amnion models. The PRP plug was stable and attached firmly to the amnion tear.
The authors concluded that they found experimental evidence that a PRP plug persisted for nearly 2 months in an amniotic fluid environment. It also provided waterproof sealing of iatrogenic defects in the amnion and chorion. Moreover, PRP stimulates cell growth and proliferation, and may thereby enhance the membrane-healing response [rx].