Considerations for Choosing a PRP Doctor

Ross Hauser, MD Considerations for Choosing a PRP Doctor

Ross Hauser, MD

There is a tremendous amount of medical literature concerning the use of Platelet Rich Plasma Injections (PRP) for degenerative joint disease. This article will concentrate on issues facing patients in choosing a doctor who offers Platelet Rich Plasma. For research and clinical application studies please refer to our article What is Platelet Rich Plasma?

Researchers are spending a lot of time testing biomedicines for patients with degenerative joint disease. Biomedicines are healing and growth factors taken from your blood and your stem cells. This research includes PRP and Stem Cell Therapy. The hope is that biomedicines will be able to replace joint replacement surgeries.

PRP Therapy is NOT a single injection of PRP although some doctors think it is

There are studies that suggest PRP may not be effective for patients. Many of these studies are shown to us by patients. In one study published in the medical journal Arthritis research and therapies, doctors describe Platelet Rich Plasma (PRP) as a “cocktail of growth factors and inflammatory mediators” drawn and prepared from the patient’s own blood that is potentially effective for cartilage repair as it can fill in the “holes” in cartilage. The problem?

Doctors in Brazil also published their research in Revista brasileira de reumatologia (the Brazilian Journal of Rheumatology) in which they also found that there is no standardization in the PRP production method, neither in the number, timing, and volume of applications and this made clear, concise results impossible in selected studies.6

In our clinic, it is common for us to see patients who still have pain after receiving PRP injections from another PRP doctor. Unfortunately, we feel that patients are rushing to get a single shot of PRP without a proper understanding of what PRP is ideal for, and why it should not be received as a standalone treatment.

Part of this reasoning comes from literature that shows in certain circumstance PRP can offer significant relief with one injection.

This was demonstrated by doctors in Switzerland who documented single PRP injections provided significant pain relief in elbow problems,2 and plantar fasciitis.3

In a May 2017 study, doctors writing in the International journal of surgery assessed the short-term results of repeated platelet rich plasma injections into the knee in patients with early osteoarthritis. The goal of the study was to help doctors determine better treatment protocol.

The researchers concluded: PRP injection appears to be effective in early symptomatic osteoarthritic knees. The results after treatment are encouraging with significant reduction in pain and improvement in knee function at 12 months after treatment when compared to the pre-treatment status. Three injections per month yielded significantly better results in short-term follow-up.4

In a study from March 2017 doctors in Turkey writing in the medical journal Knee surgery, sports traumatology, arthroscopy wrote that not only were multiple PRP injections more effective than single injections, but the multiple PRP injections were also more effective than hyaluronic acid injections in knees with early osteoarthritis.5

PRP is type of Prolotherapy, and we use it in specific types of cases to augment dextrose Prolotherapy results. If you are wondering if PRP is right for you, or why you might not have received the PRP results you were expecting, please review this article and our top considerations for PRP, using examples of patients we have seen here.

Finding a Prolotherapy – PRP Specialist

Prolotherapy is an injection technique. Its success relies heavily on the ability of the doctor to be an expert at creating the inflammatory healing response. The subject of inflammation as part of the healing cascade is covered in our article Osteoarthritic bone repair.

Most doctors who are doing PRP injections are not Prolotherapists, they are surgeons. In one interesting case, a patient had seen an orthopedic surgeon who apparently had gone to a weekend course and now was doing PRP injections.

The orthopedic surgeon as far as I could tell had absolutely no training in Prolotherapy. All he was doing was injecting PRP into an area that he normally would inject steroids.

Are you looking for a PRP doctor because you have tried physical therapy, anti-inflammatory medications, rest, ice, steroid shots, acupuncture, chiropractic care, and a lot of other different treatments and you still have pain? Instead of trying one shot of PRP to get rid of all your pain, we find it’s more efficacious to be evaluated by a PRP doctor or practitioner who is a Prolotherapist and able to treat all of your damaged, degenerated structures.

Degenerative Joint Disease is not one lesion

What are the odds that there is just one structure in your body causing your pain? In other words, if you have had pain for one year, two years, or any length of time, what is the likelihood that all of your current pain is from one isolated structure that the one shot of PRP is going to help?

Common sense is that you have more than one structure that needs repair. If that is the case, it is almost certain that one shot of PRP is not going to do the trick.

In one case a patient had received three PRP treatments for an arthritic knee without much resultant improvement. On initial physical examination in our office, it was clear the patient possessed knee instability from various ligament laxities, including the ACL and MCL.

She definitely needed to strengthen and tighten these structures to provide more stability to the knee. Once the patient was treated with Prolotherapy in addition to PRP, her pain and instability was gone. You need to ask yourself this question, “What caused the joint, meniscal, labral, or disc degeneration in the first place?” The answer is ligament laxity and/or joint instability. If this is not treated, along with the other structures associated with your pain, you are not going to get better.

Sometimes we hear that we are the first to actually examine the painful area. In other words, the patient saw six other clinicians and not one examined the area thoroughly. MRI cannot fully tell you what is wrong. You say, “…but my MRI showed a meniscal tear.” So do 60% of all MRIs! An MRI is useful if you are thinking about getting surgery.

Just as many people with knee pain, as without knee pain, have abnormalities on MRI.

One shot of PRP into a joint is not going to regenerate an injured, lax ligament that is responsible for providing joint stability.

One shot of PRP into a joint is not going to regenerate an injured, lax ligament that is responsible for providing joint stability.

The following case is a perfect example.

A patient came to see us because PRP Therapy from another physician was not helping his hamstring tendinosis. On physical examination, the patient exhibited obvious hypermobility in his entire body, especially his right knee on the side of the hamstring pain.

What he needed was a comprehensive program of PRP and Prolotherapy to his knee, as well as to the hamstring attachment on the ischial tuberosity. It was the stabilization of his knee with this Prolotherapy technique, however, that made all the difference. He was able to get back to full activities after two treatments.

Do not receive steroids before PRP

A physician who is experienced with Prolotherapy almost never uses steroid injections or NSAIDs.

We recently saw a patient whose orthopedic surgeon was injecting steroids into the area before administering the PRP. The basic premise is that PRP Prolotherapy and any other Prolotherapy stimulates healing via stimulating the inflammatory cascade in the area. Having your PRP doctor use a steroid shot before the PRP or any other type of Prolotherapy stops the healing mechanisms or the ability of the Prolotherapy to work. This is counterproductive. Instead, we used Prolotherapy on the patient, helping stabilize his joint and quickly the condition and, of course, the pain resolved.

Anti-inflammatories and Platelet Rich Plasma do not mix

We frequently see patients who come to the office stating that their physician prescribed an anti-inflammatory medication after the PRP. Again, counterproductive. PRP and other Prolotherapy treatments work by stimulating the normal inflammatory healing mechanisms. Only in very rare situations (like giving Prolotherapy to someone with inflammatory or rheumatoid arthritis) would an experienced Prolotherapist use any type of anti-inflammatory medication after Prolotherapy. A doctor who routinely uses them after Prolotherapy is just inhibiting the response of the Prolotherapy. Since you, the patient, are paying for the Prolotherapy, I would advise you not to inhibit the Prolotherapy response because that is what is going to get you better quicker!

Nutrition and overall health status is key to your healing ability

Many people heal well after PRP treatment without changing their diets all that much (or not at all). However, some people really do need to eat better in order to heal.

A typical patient who fails because of nutritional problems is one who receives one PRP treatment. They will describe that they are not getting the results they hoped to have achieved. Patients like this who come into our office will often be overweight and fatigued. They may have issue with diabetes  and hormonal imbalances.

This issue is discussed at length in our article, obesity and joint repair, and our article hormone replacement therapy and joint disease.

The PRP injection technique at Caring Medical

In basic terms, PRP involves the application of concentrated platelets, which release growth factors to stimulate recovery in non-healing injuries. PRP causes a mass influx of growth factors, such as platelet-derived growth factor, transforming growth factor and others, which exert their effects of fibroblasts causing proliferation and thereby accelerating the regeneration of injured tissues.

Specifically PRP enhances the fibroblastic events involved in tissue healing including chemotaxis (the chemical signalling that get cells that repair damage to the site of a wound), proliferation of cells (creating more cells that heal injuries), proteosynthesis (the generation of new proteins), reparation, extra-cellular matrix deposition (please see our fascinating article Extracellular matrix in osteoarthritis and joint healing) , and the remodeling of tissues.

The preparation of therapeutic doses of growth factors consists of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.)

Our methods are described in the video below

If you would like to discuss Platelet Rich Plasma – talk to our specialists. 

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1. Xie X, Zhang C, Tuan RS. Biology of platelet-rich plasma and its clinical application in cartilage repair. Arthritis Res Ther. 2014 Feb 25;16(1):204. [Epub ahead of print]

2 Glanzmann MC, Audigé L. Platelet-rich plasma for chronic lateral epicondylitis: is one injection sufficient? Arch Orthop Trauma Surg. 2015 Dec;135(12):1637-45. doi: 10.1007/s00402-015-2322-7. Epub 2015 Aug 30.

3 Jain K, Murphy PN, Clough TM. Platelet rich plasma versus corticosteroid injection for plantar fasciitis: A comparative study. Foot (Edinb). 2015 Dec;25(4):235-7. [Pubmed]

4 Huang PH, Wang CJ, Chou WY, Wang JW, Ko JY. Short-term clinical results of intra-articular PRP injections for early osteoarthritis of the knee. Int J Surg. 2017 May 2;42:117-122. [Pubmed]

5 Görmeli G1, Görmeli CA2, Ataoglu B3, Çolak C4, Aslantürk O5, Ertem K5. Knee Surg Sports Traumatol Arthrosc. 2017 Mar;25(3):958-965. doi: 10.1007/s00167-015-3705-6. Epub 2015 Aug 2. [Pubmed]

6 Knop E, Paula LE, Fuller R. Platelet-rich plasma for osteoarthritis treatment. Rev Bras Reumatol Engl Ed. 2016 Mar-Apr;56(2):152-64. [Pubmed]

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