Platelet Rich Plasma in the Treatment of Orthopaedic Injuries

Overview

As a third year DPT student who is interested in the orthopedic setting, I have noticed a surge in popularity surrounding platelet rich plasma (PRP) in the use for multiple injuries. For my final capstone assignment, I chose to look at PRP in the current literature. These materials will be used to present at ICE Sports Therapy for my final in-service in July 2014.

Since the 1970s, platelet rich plasma has been studied as one of the autologous products thought to have influence on biological healing.¹ Platelet rich plasma (PRP) is a concentrate of platelets and the associated growth factors (GF) which is obtained through a patient’s own blood by withdrawal and centrifugation.² PRP did not start to gain popularity until the 1990s.³ PRP was first introduced for maxillofacial and plastic surgery but has since gained popularity and diversified its areas of indication.³ PRP is now established in fields of dentistry, dermatology, plastic and maxillofacial surgery, acute trauma, cosmetic surgery, and veterinary medicine.⁴ More recently, PRP has been introduced in the orthopedic setting. In 2009, PRP was raised to a new level of public awareness when The New York Times detailed the use of PRP to treat an injured Pittsburgh Steelers player before the Superbowl.⁵ This is only one example of mainstream media that is making PRP more popular among professional and recreational athletes.  In 2009 the PRP market was valued at $45 million and is expected to be more than $120 million by 2016.⁶

PRP is a simple, efficient, and minimally invasive method of obtaining a natural concentration of autologous growth factors.⁴ PRP has demonstrated the potential to modify the natural healing pathway in several ways. In the most simple of terms it is suggested that the healing potential is created by the ability of PRP to recruit, proliferate, and differentiate cells.² The increased concentration of GFs and bioactive proteins released by activated platelets increases regeneration of tissue and restore biomechanical properties that are similar to normal tissue. The process also amplifies the surge of chemical mediators to the injured area that mimics the initial stage of inflammatory response.² In the normal healing process, platelets are responsible for clotting the blood and for homeostasis. Once a mediator activates them, the platelets degranulate and release bioactive proteins or growth factors that also have a role in healing. These growth factors include transforming growth factor-beta, platelet-derived growth factor, insulin-like growth factors I and II, fibroblast growth factor, epidermal growth factor, vascular endothelial growth factor, and endothelial cell growth factor.⁶ Some evidence suggests that PRP may have an inhibitory effect on certain proinflammatory cytokines that could be detrimental in early healing stages.² The enhancement to reparative action and the minimizing power of tissue breakdown may allow local PRP application to speed up tissue healing process. This could lead to a wide range of potential applications and advantages for improved outcomes and faster recovery.²

From even just a short glance at the research on PRP, one will immediately notice the controversies and lack of standardization. This paper and presentation discusses the history of PRP, the method of which it is prepared and applied, and expands on some of the current literature in the orthopaedic domain. It also addresses legal issues within different organizations as well as many controversies of PRP in current literature. The paper concludes with a discussion on mesenchymal stem cells and the potential for future studies.

Needs Assessment

My final clinical rotation will take place in an advanced orthopedic sports therapy practice. As I began to research topics that were interesting to me, I also wanted to know more about how I could educate my peer therapists on a topic they may not be so familiar with. I spoke to Marty Jaramillo, owner of ICE Sports Therapy and my future ACCE and he was very interested in having this information transformed into my final in-service. I will have 60-90 minutes to expand on this topic and he hopes to “create a foundation for additional discussion on the future of stem cell treatments in orthopaedics.” All members of the audience will be asked to complete the survey at the conclusion of the discussion.

As physical therapists it will be critical for us to understand possible interventions that our patients may encounter. Even if the evidence supporting the treatment is being questioned and seeking standardization, we must still understand the implication and theory so we can better educate and treat our patients with confidence.

Learning Objectives

1. Become familiar with the molecular phases of platelet rich plasma and the preparation methods used to formulate this compound
2. Compare and contrast protocol of current literature focused on PRP extraction and implementation
3. Compare and contrast outcomes used with different orthopaedic injuries
4. Compare PRP to conservative treatments of orthopaedic injury
5. Better understand the regulations of PRP used in professional sports globally
6. Understand the future of PRP and the direction in which research is heading
7. Create a patient handout that can be used as a general educational tool for patients curious about PRP
8. Create a literature review and PowerPoint file that will be substantial for presenting a 60 minute in-service to elite sports physical therapists

Final Products

PRP Literature Review

PRP Presentation

PRP_Patient Handout

Acknowledgments

I would like to give many thanks to Mike Gross, Mike McMorris, and Casey Banta for all of their wonderful feedback and guidance. I also would like to thank all physical therapists and doctoral students for taking the time to delve into this topic with me. Please feel free to fill out the evaluation form and e-mail it to me at lauren_diamond@med.unc.edu or comment below.

References

1. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: From basic science to clinical applications. Am J Sports Med. 2009;37(11):2259-2272. doi: 10.1177/0363546509349921; 10.1177/0363546509349921.
2. Taylor DW, Petrera M, Hendry M, Theodoropoulos JS. A systematic review of the use of platelet-rich plasma in sports medicine as a new treatment for tendon and ligament injuries. Clin J Sport Med. 2011;21(4):344-352. doi: 10.1097/JSM.0b013e31821d0f65; 10.1097/JSM.0b013e31821d0f65.
3. Marx R. Platelet-rich plasma: Evidence to support its use. Journal of oral and maxillofacial surgery. 2004;62(4):489.
4. Cole BJ, Seroyer ST, Filardo G, Bajaj S, Fortier LA. Platelet-rich plasma: Where are we now and where are we going? Sports Health. 2010;2(3):203-210. doi: 10.1177/1941738110366385.
5. Schwarz A. A promising treatment for athletes, in blood. . 2009.
6. Sheth U, Simunovic N, Klein G, et al. Efficacy of autologous platelet-rich plasma use for orthopaedic indications: A meta-analysis. J Bone Joint Surg Am. 2012;94(4):298-307. doi: 10.2106/JBJS.K.00154; 10.2106/JBJS.K.00154.