Regenerative Injection Therapies:
PLATELET -RICH PLASMA (PRP) TREATMENTS
PRP is a remarkable Regenerative Medicine treatment. Platelets in our blood contain many natural growth factors and healing proteins, and are involved directly in early healing and repair processes in any injury.
The procedure involves a simple in office blood draw, following which the blood is centrifuged and specially processed to both extract and concentrate the platelets. The PRP is then injected directly into an arthritic joint or damaged area. Typically the whole process from start to finish can be completed within an hour, the down time being the wait for the preparation of the PRP, which takes about 15-20 minutes. Repeat treatments depend on the type of injury or problem; for example in most knee arthritis a course of 3 PRP treatments is the norm, about a month apart.
CSOM has been utilizing PRP since July 2017 with great success, and because it utilizes your own blood it is a very safe procedure. Conditions that may be treated include: Joint pain and arthritis, rotator cuff damage, tennis and golfer’s elbow, achilles tendon problems, plantar fasciitis, back and neck pain and most sprains and strains.
Every patient is different, and each individual needs to be carefully assessed for suitability for any of the RIT.
What is Prolotherapy?
Prolotherapy is injection with the intent of repairing connective tissue – ligament, tendon or cartilage. As a treatment it has been around for decades, with increasing traction as more level one (high quality) evidence comes to light.
Dextrose (12.5 to 25% in concentration, mixed usually with saline and aneasthetic) is injected into weak, loosened or otherwise damaged soft tissues as described above, typically at what is referred to as a fibro-osseous junction (soft tissue to bony attachment). It generates a low grade brief inflammatory reaction, essentially the same the body uses following injury. ‘Good’ inflammation (that which uses arachidonic acid pathways) is critical to all healing, and such inflammation must precede cell regeneration and then tissue remodeling. It is not the same as the ‘bad’ inflammation we see in diseases like rheumatoid arthritis.
How is it given?
Injections are usually repeated in a series, sometimes only 1-3 one to four weeks apart for small areas or more recent injuries such as an ankle sprain, or 4-6 + about once a month for more chronic problems, such as long standing back pain. Prolotherapy can generate growth of new, normal tissue, not scar tissue. As time goes on the patient can be giving the doctor feedback on any need for further injections. Once the pain or dysfunction is sufficiently controlled or even eradicated, no more treatment is necessary. This is often permanent, or a ‘top up’ might be required years down the line. There is no limit to the number of treatments, but if someone isn’t starting to improve after 5-6 sessions then they may not benefit in that particular instance.
What are the after effects?
Healing can be slow (you’re taking the slow boat to China and not flying there) but it is safe; dextrose is a natural fuel for the body and is not a drug. Some patients do get better quickly, and this is likely due to the positive benefits of dextrose on nerves as well (see section on perineural injection therapy).
There is little down time. You may feel sore and stiff in the first day or two, but the effect typically settles quickly, and activity is usually encouraged. Use of anti-inflammatory medication however is discouraged for the first few days, in order to maximize any beneficial inflammatory effect.
PERINEURAL INJECTION THERAPY
What is Perineural Injection Therapy?
There are two types. Let’s first look at Superficial Perineural Injection Therapy. It has been clinically observed that injection of a low concentration dextrose (5%) solution with tiny needles just under the skin is analgesic to nerve pain, and usually within seconds. It may need to be repeated, but several treatments can lead to progressive and cumulative benefit.
Deep Perineural injection Therapy takes the same solution but works on deeper areas of nerve irritation and inflammation, often where nerves feed through fascial /muscle planes and tunnels and can get caught or pinched, or where they curve and catch around harder bony borders. This injection requires the precision of real-time ultrasound guidance to hydrodissect, stretch and free up the tissue surrounding the nerve. A very recent study showed that using dextrose to hydrodissect about the median nerve in carpal tunnel syndrome proved much more successful than a cortisone injection at the 6 month mark.
How does it work?
We now recognize another type of inflammation called neurogenic inflammation, produced by certain small sensory nerves that are protein producing (peptidergic). Sometimes these proteins can be damaging rather then healing, in which case they can generate neurogenic inflammation. This isn’t a ‘good’ inflammation, and it also doesn’t respond to oral anti- inflammatory medications. Dextrose in low concentration has been shown to reduce it, very often creating an immediate analgesic effect. Several treatments may be required, cumulative in effect, the goal being to restore normal nerve function. Depending on where the nerve is affected, several areas along a nerve pathway may need to be treated, using both superficial and deep infiltrations as necessary.
Note that this isn’t quite the same as prolotherapy, which uses stronger dextrose injections in ligaments, tendons and cartilage to initiate a healing inflammation with new tissue growth. But this is why we think some patients do respond faster than anticipated to prolotherapy, as the dextrose is probably down regulating local neurogenic inflammation at the same time as it stimulates healing (AA) inflammation.