A Physio’s Guide to PRP Therapy and Injections

PRP injections have recently gained popularity as a treatment option for stubborn tendon injuries. As a physiotherapist over the last 12 months I have had more and more clients ask me about PRP and its effectiveness. I have also observed an increase in the number of clients who have had PRP injections.

Normally it is the treating physiotherapist, sports doctor, or even general practitioner who will suggest that PRP may be a viable treatment option in an attempt to facilitate tendon recovery and healing.

WHAT IS PRP THERAPY?

PRP is an acronym for Platelet Rich Plasma therapy which is administered through a series of injections.

PRP therapy is performed by taking venous blood from a patient. The blood is then handled by placing it in a centrifuge where it will be spun at high speed in order to separate the blood’s constituents. Following time in the centrifuge the blood will appear to be in three distinct ‘zones’: red blood cells(bottom), blood plasma (middle), and platelet rich plasma (top). The ampoules into which the blood are placed contains a separating gel. 6mls of platelet rich plasma are required for injection.

It is the platelet rich plasma which is kept and later injected into the affected tendon or site of injury. This platelet rich plasma has concentrated platelets of which the platelets may be best thought of as little bundles of various growth factors and healing factors, which are believed to allow healing to occur faster.

Interestingly the best platelet rich plasma has the white blood cells removed.

 

WHO IS PRP INJECTION THERAPY POTENTIALLY FOR?

Typically clients who have suffered for a lengthy period with frustrating and slow to improve tendon injuries such as plantar fasciitis, achilles tendon, patellar tendon,  tennis elbow, and hamstring tendon injuries , can be introduced to the PRP therapy as a possible ‘next step’ in their quest to function without pain.

PRP can also be used as a treatment for recalcitrant joint pains such as knee, shoulder, or hip joint pain. Typically these will be people who have significant ongoing pain despite the use of pain medication, weight loss, and/or physiotherapy treatment.

HOW IS PRP THERAPY PERFORMED?

 PRP therapy is performed with the following steps:

1. The procedure involves drawing two lots of blood from the patient’s arm.

2.  Local anaesthetic is injected near the site of injury after a few minutes the PRP is injected.

3. The benefits should be noticed about 4-8 weeks after the first injection.

4. A second injection is usually recommended one month later (this is normally recommended to lengthen the period of symptom pain relief).

5. Further ‘top-up’ injections may also be recommended depending on the patient’s symptoms at 6, 12 or 24 months.

WHO PERFORMS PRP THERAPY?

PRP injections may be administered via Sports Doctors, Radiologists, or Orthopaedic surgeons

WHAT DOES THE RESEARCH SAY ABOUT PRP THERAPY?

The use and clinical validation of PRP as a treatment option for joint and tendon injuries is still in the relatively early stages.

Perhaps the most guiding of recent studies was a 2014 Cochrane Review which cited 19 studies that looked at the use of PRP injections in studies compared against a variety of controls (such as no PRP injections, dry needling, placebo injection, and blood injection). These 19 studies involved in excess of 1000 patients (subjects).

The 19 studies covered 8 different injury types ranging from post-operative knees to elbows, and Achilles tendon problems.

 The Cochrane Review cites that:

The quality of the evidence is very low, partly because most trials used flawed methods that mean their results may not be reliable. The trials also used different ways of preparing and applying the platelet-rich plasma.

The review further reports that data could only be pooled from 11 of the 19 studies with a total of 45% of the 1088 subjects.

 The conclusions drawn were:

1. Very weak or low quality evidence existed for a slight benefit of PRP injections for pain relief in the short term (up to three months following injection).

2.PRP injections were reported to not make a significant difference in function in the short, medium or long term.

3. In summary the collaborators of the review stated that:

The available evidence is insufficient to support the use of PRT for treating musculo-skeletal soft tissue injuries or show whether the effects of PRP vary   according to the type of injury.

A recent study concluded that PRP injection therapy was not efficacious for chronic tennis elbow sufferers -click HERE.

WHAT ARE THE SIDE EFFECTS?

• Common side effects can include post injection pain for 24-48 hours, or swelling & bruising at the injection site.

• Most patients will experience varying degrees of pain and discomfort the next day.

• Less common side effects may include: dizziness, nausea or feeling unwell.

• Fortunately severe complications, such as infection are very rare.

WHAT IS THE COST?

The cost of injections is typically in the vicinity of $300-$500 per injection. PRP injections do not attract a Medicare Rebate.

MY CLOSING THOUGHTS:

Despite the paucity of current evidence that exists I am of the opinion that PRP therapy and injections may be a viable next step and treatment option in particular for patient’s suffering from recalcitrant and slow responding tendon injuries.

Personally I have carried a low grade Achilles tendon niggle for the better part of 12 months now, even after focussed periods of rehabilitation.  While it has not forced me to stop running I notice that the tendon is still tender to touch. If my pain persists any longer than another 6 months I will likely pursue PRP myself.

TIPS:

1. Drink lots of water and avoid caffeine (a diuretic) before you go to have your blood taken. This will make the blood drawing and vein location process easier.

2. Most patients will feel a slight sting on injection of the PRP. A local anaesthetic is used.

3. People who suffer from platelet disorders cannot have PRP-if unsure check with your GP.

4. You can drive your vehicle after injections.

5. The injection site must be kept clean and dry for 24hrs

6.  Vigorous exercise and alcohol is best avoided 24hrs following the injection.

7. Build back into exercise and activity gradually following PRP injections.

If you enjoyed this article or have your own experience to share please post a comment.

Brad Beer (APAM)

POGO Founder, Author, and Physiotherapist

REFERENCES:

1. The platelet rich plasma  Patient Handout clinic  http://www.prpclinic.com.au/

2. Moraes VY, Lenza M, Tamaoki M, Faloppa F, Belloti J. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD010071. DOI: 10.1002/14651858.CD010071.pub3 – See more at: http://summaries.cochrane.org/CD010071/MUSKINJ_platelet-rich-therapies-for-musculoskeletal-soft-tissue-injuries#sthash.1Hw7Nd5w.dpuf