Platelet-rich plasma

Platelet-rich plasma
Intervention
MeSH D053657

Platelet-rich plasma (abbreviation: PRP) is blood plasma that has been enriched with platelets. As a concentrated source of autologous platelets, PRP contains several different growth factors and other cytokines that can stimulate healing of soft tissue. Platelet-rich plasma therapy is an old therapy and used extensively in specialities of dermatology, orthopedics and dentistry. Platelet rich plasma therapy utilizes growth factors present in alpha granules of platelets in an autologous manner. Main indications in dermatology for PRP are androgenetic alopecia, wound healing, face rejuvenation etc. For preparation of PRP, various protocols are used and no standard protocol exists but main principles essentially involve concentrating platlets in a concentration of 3–5 times the physiological value and then injecting this concentrated plasma in the tissue where healing or effect is desired.[1] As of 2016, no large-scale randomized controlled trials have confirmed the efficacy of PRP as a treatment for musculoskeletal or nerve injuries, the accelerated healing of bone grafts, or the reduction of androgenic hair loss.

History

PRP was first developed in the 1970s and first used in Italy in 1987 in an open heart surgery procedure. PRP therapy began gaining popularity in the mid 1990s. It has since been applied to many different medical fields such as cosmetic surgery, dentistry, sports medicine and pain management.

The number of peer reviewed publications studying the PRP's efficacy has increased dramatically since 2007.[2]

Components

Whole blood placed in Centrifuge prior to two stage centrifugation

The efficacy of certain growth factors in healing various injuries and the concentrations of these growth factors found within PRP are the theoretical basis for the use of PRP in tissue repair.[3] The platelets collected in PRP are activated by the addition of thrombin and calcium chloride, which induces the release of the mentioned factors from alpha granules. The growth factors and other cytokines present in PRP include:[3][4]

Preparation

Blood drawn from patient
Removal of PRP after double centrifugation
PRP is Injected into area of injury via ultrasound guidance

As of 2009 there have been two PRP preparation methods approved by the U.S. Food and Drug Administration.[5] Both processes involve the collection of the patient's whole blood (that is anticoagulated with citrate dextrose) before undergoing two stages of centrifugation (TruPRP) (Harvest) (Pure PRP) designed to separate the PRP aliquot from platelet-poor plasma and red blood cells.[5] In humans, the typical baseline blood platelet count is approximately 200,000 per µL; therapeutic PRP concentrates the platelets by roughly five-fold.[6] There is broad variability in the production of PRP by various concentrating equipment and techniques.[7][8][9]

Clinical applications

In humans, PRP has been investigated and used as a clinical tool for several types of medical treatments, including nerve injury,[4] chronic tendinitis,[10][11][12] plantar fasciitis,[13] osteoarthritis,[14] cardiac muscle injury,[15] and androgenic alopecia,[16][17] for bone repair and regeneration,[18] in plastic surgery,[19] colorectal surgery[20] and oral surgery[21]

PRP has received attention in the popular media as a result of its use in treating sports injuries in professional athletes.[22][23][24][25]

The cost of a PRP treatment in the U.S. has been quoted as $1000 out-of-pocket expenses, as it is usually not covered by health insurance.[25]

PRP has been used experimentally in the treatment of empty nose syndrome[26]

Clinical validity

As of 2016 results of basic science and preclinical trials have not yet been confirmed in large-scale randomized controlled trials. A 2009 systematic review of the scientific literature found there were few randomized controlled trials that adequately evaluated the safety and efficacy of PRP treatments and concluded that PRP was "a promising, but not proven, treatment option for joint, tendon, ligament, and muscle injuries".[27]

In 2009 a pilot study investigating the effects of PRP on 20 male athletes with a mean injury history of 20.7 months of pain due to chronic patellar tendinosis, also known as jumpers knee, found statistically significant improvements in physical function and pain levels. 6 month follow up's after treatment showed participants returned to 90% of pre-injury sports activity levels, and 80% of participants were able to return to sports within 4 months of treatment. [28]

A 2010 Cochrane analysis on PRP use in sinus lifts during dental implant placement found no evidence that PRP offered any benefit.[21]

As of 2011, PRP use for nerve injury and sports medicine has produced "promising" but "inconsistent" results in early trials.[4]

A 2013 review stated more evidence was needed to determine PRP's effectiveness for hair regrowth.[29]

A 2014 Cochrane analysis for PRT use to treat musculoskeletal injuries found very weak (very low quality) evidence for a decrease in pain in the short term, up to three months and no difference in function in the short, medium or long term. There was weak evidence that suggested that harm occurred at comparable, low rates in treated and untreated people.[30]

A 2016 systematic review and meta-analysis of randomized controlled clinical trials for PRP use to augment bone graft found only one study reporting a significant difference in bone augmentation, while four studies found no significant difference.[31]

Since 2004, proponents of PRP therapy have argued that negative clinical results are associated with poor-quality PRP produced by inadequate single spin devices. The fact that most gathering devices capture a percentage of a given thrombocyte count could bias results, because of inter-individual variability in the platelet concentration of human plasma and more would not necessarily be better.[6] The variability in platelet concentrating techniques may alter platelet degranulation characteristics that could affect clinical outcomes.[4]

Use in horses

Platelet-rich plasma is used in horses for treatment of equine lameness due to tendon and ligament injury, wounds, fractures, bone cysts, and osteoarthritis.

Implications for doping

Some concern exists as to whether PRP treatments violate anti-doping rules.[3] As of 2010 it was not clear if local injections of PRP could have a systemic impact on circulating cytokine levels, affecting doping tests and whether PRP treatments have systemic anabolic effects or affect performance.[3] In January 2011, the World Anti-Doping Agency removed intramuscular injections of PRP from its prohibitions after determining that there is a "lack of any current evidence concerning the use of these methods for purposes of performance enhancement".[32]

According to the Baltimore Sun, Zach Britton had PRP injections in his left shoulder in March 2012, Orioles first baseman Chris Davis underwent two PRP injections to speed the healing and recovery of an oblique injury in April 2014, and Dylan Bundy had the procedure in April before undergoing Tommy John surgery in June 2014.[33]

See also

References

  1. ↑ "PRP Therapy | Hair Loss Treatment". OC Hair Restoration. Orange County, California. Retrieved 5 July 2016.
  2. ↑ platelet-rich plasma evidence Results by year graph, PubMed.gov, National Center for Biotechnology Information, U.S. National Library of Medicine, retrieved 23 March 2016
  3. 1 2 3 4 Borrione P, Gianfrancesco AD, Pereira MT, Pigozzi F (2010). "Platelet-rich plasma in muscle healing". Am J Phys Med Rehabil. 89 (10): 854–61. doi:10.1097/PHM.0b013e3181f1c1c7. PMID 20855985.
  4. 1 2 3 4 Yu W, Wang J, Yin J (2011). "Platelet-Rich Plasma: A Promising Product for Treatment of Peripheral Nerve Regeneration After Nerve Injury". Int J Neurosci. 121 (4): 176–180. doi:10.3109/00207454.2010.544432. PMID 21244302.
  5. 1 2 Arora NS, Ramanayake T, Ren YF, Romanos GE (2009). "Platelet-rich plasma: a literature review". Implant Dent. 18 (4): 303–10. doi:10.1097/ID.0b013e31819e8ec6. PMID 19667818.
  6. 1 2 Marx RE (2004). "Platelet-rich plasma: evidence to support its use" (PDF). Journal of Oral and Maxillofacial Surgery. 62 (4): 489–96. doi:10.1016/j.joms.2003.12.003. PMID 15085519.
  7. ↑ Dohan Ehrenfest DM, Rasmusson L, Albrektsson T (2009). "Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF)". Trends in Biotechnology. 27 (3): 158–67. doi:10.1016/j.tibtech.2008.11.009. PMID 19187989.
  8. ↑ Gonshor A (2002). "Technique for producing platelet-rich plasma and platelet concentrate: background and process". The International Journal of Periodontics & Restorative Dentistry. 22 (6): 547–57. PMID 12516826.
  9. ↑ Weibrich G, Kleis WK, Hafner G, Hitzler WE, Wagner W (2003). "Comparison of platelet, leukocyte, and growth factor levels in point-of-care platelet-enriched plasma, prepared using a modified Curasan kit, with preparations received from a local blood bank". Clinical Oral Implants Research. 14 (3): 357–62. doi:10.1034/j.1600-0501.2003.00810.x. PMID 12755786.
  10. ↑ Monto R (2012). "Platelet rich plasma for chronic achilles tendinosis". Foot and Ankle International. 33 (5): 379–385. doi:10.3113/FAI.2012.0379\url=http://fai.sagepub.com/content/33/5/379.short.
  11. ↑ Mishra A, Pavelko T (2006). "Treatment of chronic elbow tendinosis with buffered platelet-rich plasma". The American Journal of Sports Medicine. 34 (11): 1774–8. doi:10.1177/0363546506288850. PMID 16735582.
  12. ↑ Mishra A, Woodall J, Vieira A (2009). "Treatment of tendon and muscle using platelet-rich plasma". Clinics in Sports Medicine. 28 (1): 113–25. doi:10.1016/j.csm.2008.08.007. PMID 19064169.
  13. ↑ Monto R (2014). "Platlet-rich plasma efficacy versus corticosteroid injection for chronic severe plantar fasciitis". Foot and Ankle International. 35 (4): 313–318. doi:10.1177/1071100713519778.
  14. ↑ Andia I, Sanchez M, Maffulli N (2012). "joint pathology and platelet-rich plasma therapies". Expert Opinion in Biological Therapies. 12 (1): 7–22. doi:10.1517/14712598.2012.632765. PMID 22171664.
  15. ↑ Mishra A, Velotta J, Brinton TJ, et al. (2010). "RevaTen platelet-rich plasma improves cardiac function after myocardial injury". Cardiovasc Revasc Med. 12 (3): 158–63. doi:10.1016/j.carrev.2010.08.005. PMID 21122486.
  16. ↑ Khatu, Swapna S; More, Yuvraj E; Gokhale, Neeta R; Chavhan, Dipali C; Bendsure, Nitin (2014). "Platelet-Rich Plasma in Androgenic Alopecia: Myth or an Effective Tool". Journal of Cutaneous and Aesthetic Surgery. 7 (2): 107–110. doi:10.4103/0974-2077.138352. ISSN 0974-2077. PMC 4134641Freely accessible. PMID 25136212.
  17. ↑ Chaudhari, Nitin D; Sharma, Yugal K; Dash, Kedar; Deshmukh, Palak (2012). "Role of Platelet-rich Plasma in the Management of Androgenetic Alopecia". International Journal of Trichology. 4 (4): 291–292. doi:10.4103/0974-7753.111222. ISSN 0974-7753. PMC 3681120Freely accessible. PMID 23766623.
  18. ↑ Griffin XL, Smith CM, Costa ML (2009). "The clinical use of platelet-rich plasma in the promotion of bone healing: a systematic review". Injury. 40 (2): 158–62. doi:10.1016/j.injury.2008.06.025. PMID 19084836.
  19. ↑ Por YC, Shi L, Samuel M, Song C, Yeow VK (2009). "Use of tissue sealants in face-lifts: a metaanalysis". Aesthetic Plastic Surgery. 33 (3): 336–9. doi:10.1007/s00266-008-9280-1. PMID 19089492.
  20. ↑ Segura-Sampedro, Juan Jose (2016). Factibilidad y seguridad del plasma rico en factores de crecimiento (prgf) en el tratamiento de la fístula anal criptoglandular. Universidad de Sevilla.
  21. 1 2 Esposito M (Spring 2010). "Effectiveness of sinus lift procedures for dental implant rehabilitation: a Cochrane systematic review.". Eur J Oral Implantol. 3 (1): 7–26. PMID 20467595.
  22. ↑ Alan Schwarz (2009-02-16). "A Promising Treatment for Athletes, in Blood". New York Times. New York.
  23. ↑ Gretchen Reynolds (2011-01-26). "Phys Ed: Does Platelet-Rich Plasma Therapy Really Work?". New York Times.
  24. ↑ Carina Storrs (2009-12-18). "Is Platelet-Rich Plasma an Effective Healing Therapy?". Scientific American.
  25. 1 2 Gina Kolata (2010-01-12). "Popular Blood Therapy May Not Work". New York Times.
  26. ↑ "Empty Nose Syndrome". care.american-rhinologic.org. Retrieved 2016-06-12.
  27. ↑ Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA (2009). "Platelet-rich plasma: from basic science to clinical applications". Am J Sports Med. 37 (11): 2259–72. doi:10.1177/0363546509349921. PMID 19875361.
  28. ↑ Kon, Alizavata (June 2009). "Platelet-rich plasma: New clinical application: A pilot study for treatment of jumper's knee". Injury. 40 (6): 598–603. doi:10.1016/j.injury.2008.11.026. ISSN 0020-1383.
  29. ↑ Valente Duarte de Sousa, Isabel Cristina; Tosti, Antonella (May 2013). "New investigational drugs for androgenetic alopecia". Expert Opinion on Investigational Drugs. 22 (5): 573–589. doi:10.1517/13543784.2013.784743. ISSN 1744-7658. PMID 23550739.
  30. ↑ Moraes VY (April 2014). "Platelet-rich therapies for musculoskeletal soft tissue injuries". Cochrane Database Syst Rev. 29 (4): CD010071. doi:10.1002/14651858.CD010071.pub3.
  31. ↑ Pocaterra A, Caruso S, Bernardi S, et al. Effectiveness of platelet-rich plasma as an adjunctive material to bone graft: a systematic review and meta-analysis of randomized controlled clinical trials.Int J Oral Maxillofac Surg. 14 March 2016. pii: S0901-5027(16)00072-2. DOI: 10.1016/j.ijom.2016.02.012.
  32. ↑ "World Anti-Doping Agency announces changes to Prohibited List". Irish Medical Times. 2011-01-10.
  33. ↑ Dan Connolly Orioles first baseman Chris Davis receives two PRP injections Baltimore Sun, April 29, 2014
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