The other day we received an email from a person who had Platelet-Rich Plasma (PRP) Injection that failed to produce any results. “Not impressed, did not work for me. Had it done for my back,” she said. Comments like these are charged with emotions as almost all of these patients have paid for PRP injections out of their own pockets. That’s why the same patient also added later “…but did empty my wallet.” For us, her comment was one of the kinder ones. Others, who were really mad at seeing their money wasted, called it a sham, quackery, and “ways for doctors to make money.” We understand this sentiment. And we can’t argue with the fact that these treatments may have been failures.
But the thing is very few people, including some expert physicians understand why these PRP injections fail.
What The Tremendous Popularity Of PRP Means
In the 1990s, there were about 150 new research articles on Platelet-Rich Plasma every year. At least in the Pubmed database. Back then, only a select group of physicians who really understood the treatment actually offered it to their patients. Now, just this year alone, there were more than 600 new articles. The trend line has gone from a gradual climb to a “U curve” or exploding popularity.
And so did the number of physicians offering this treatment.
Certainly, money wasn’t the objective for those physicians – for if it were, the best ways to do it would’ve been to prescribe a battery of tests, drugs and surgeries approved by insurance companies. Instead, the physicians started offering it once they knew well the inherent benefits of an interventional autologous medicine like Platelet-Rich Plasma.
The problem is, not all physicians were that passionate about it.
Some did it because patients asked for it. Some did it because everyone else was doing it. Still others just wanted to experiment with it casually.
And so not all Platelet-Rich Plasma injections worked. That’s why, as the treatment exploded in popularity, we saw a small portion of those treatments end up being a waste of the patient’s money – and that gets talked about a lot because, as I mentioned above, the patient usually has huge emotional response to the outcome.
But on the other hand, majority of the patients are happy about their results.
“I had it done on my injury and MAN, IT REALLY WORKS!!!”
That’s another response we got on the SAME DAY that this women told us it didn’t work for her. Another physician also told us the very same day, “PRP works great. We have had fantastic results on patients in the office.”
So what’s making the difference?
Why do some PRP treatments work spectacularly while some others turn out to be a dud?
That’s what we’ll explain in the rest of this post here. There are six main reasons why it can fail. Plus a seventh no-so-common reason. Let’s look at them one by one.
1. Improper Selection of Patients
As much as the Platelet-Rich Plasma injection enthusiasts would like beat the drum of its universality of application, there are certain instances where a PRP injection may be unnecessary. The classic case is demonstrated in the 2015 Double-Blind Randomized, Placebo-controlled Study that showed that PRP injections are NOT beneficial at all.
According to expert researchers we subscribe to, it is clear that this study had selected the WRONG PATIENTS!!!
Here’s what that means. This study, conducted by researchers at Cooper Medical School of Rowan University, New Jersey, was done in the emergency care department where patients who’d just had a ankle sprain were given a Platelet-Rich Plasma Injection.
First of all, ankle sprains are relatively acute medical condition, commonly occurring due to over-stretching and tearing of the muscle or tendon. And they’re usually healed on their own. The thing that emergency care physicians usually do for this condition is to put ice packs or local anesthetic to numb the pain so the patient can rest. For patients who’re very active, their body is able to heal itself from most of these types of ankle sprains very rapidly. For them, a PRP injection might not accelerate healing. On the other hand, because injections break up the tissue and poke holes, it can actually cause unnecessary complications.
That’s why successful studies on Platelet-Rich Plasma Injections are almost always done on chronic wounds and injuries that wouldn’t heal on its own. If you’re out to test PRP’s efficacy, the untreated-by-PRP “control group” should be non-healable so we can determine clearly the effects of PRP.
So definitely, Platelet-Rich Plasma injections are not ideal for emergency care.
The same is true for patients on the other end of the spectrum. That is the category of patients who’d been on steroids and drugs for a long time and are in the very advanced stages of the disease. Although there might be hope, Platelet-Rich Plasma might not be enough to reverse course here.
The ideal candidate for Platelet-Rich Plasma injection is a patient who has a relatively new, chronic musculoskeletal condition and whose only other option is surgery or heavy steroid/drug use.
2. Use of certain drugs
One of the other reasons why Platelet-Rich Plasma may not be ideal for emergency care patients is that when patients come in with intense pain, it’s a common practice for the ER physician to administer powerful local anesthetics and/or steroids in high dose. The problem with both of them is that they are are known to be toxic to stem cells and growth factors as shown here here, here and here. So if you’re using these steroids, anesthetics or drugs, it is recommended to wait till the patient can get off of them before applying Platelet-Rich Plasma. Otherwise, the toxicity of the chemicals may limit Platelet-Rich Plasma’s ability to recruit stem cells to the area.
For example, the local anesthetic Marcaine is found to be extremely harmful to stem cells even in small quantities. So as a general practice, the patient has to avoid harmful steroids, anesthetics and drugs at the time or up to 48 hours prior to PRP injections.
3. Lack of Rehab
It’s been reported that PRP injection works well when combined with the physical therapy for sports injuries. However, some physicians mistakenly see PRP injections as an alternative to physical therapy. Hence the comparisons like these where PRP is pitted as a rival to physical therapy. The fact is Platelet-Rich Plasma can only supplement the effects of a proper rehabilitation program as illustrated in this study which demonstrated that PRP + physiotherapy is more effective than Dry Needling + Physiotherapy for patellar tendonisis.
There is one thing we need to add to that though. Most PRP injections are done in a way that breaks up scar tissue and triggers new healing response to which the platelets can respond. So the best post-Platelet-Rich Plasma treatment rehab program is one which treats the patients as if they just had an acute injury. Meaning, the physiotherapy regimen following a PRP injection has to aim at square one – stimulation of blood flow to the injured area to provoke the inflammatory response. This is a different approach than the usual where the PT tries to attenuate the inflammatory response.
4. Under dosing
Under-dosing is a serious problem in this field. If you’re using PRP with below 3X platelet concentration, you’re under-dosing your patients. An example is the PT vs PRP study we highlighted earlier. Not only did they mistakenly conclude that Platelet-Rich Plasma could be an alternative to Physiotherapy, they were severely under dosing the patients by using PRP with 2.1-2.5X concentration of platelets.
Studies have shown that a concentration of at least 1,000,000 platelets/µl is needed for optimal therapeutic benefits. That is 5X the concentration of platelets in normal whole blood. Here is one such study.
That is the very reason why we advocate not using Gel-based PRP Kit for PRP separation. The problem with gel-based kit is that most of the platelets will get trapped in the gel. Instead a kit like DrPRP kit gives you 5X-9X platelets because it uses a mechanical separation process while giving the same 1-step convenience of gel separators.
5. Using PRP as just another injectate
There is a fundamental difference between Platelet-Rich Plasma based orthopedic intervention and typical modern surgical and drug-based treatment. And that is surgery and the drugs are designed to eliminate symptoms of diseases. For example, pain is one of many symptoms that occur when a certain part of the body is out of balance. By taking a drug, steroid, NSAID or even undergoing surgical correction, the physician hopes that the pain goes away. This approach has led to all the problems that we face in modern orthopedic medicine. Because when we treat symptoms, the underlying problems usually don’t go away.
But scores of physicians look at Platelet-Rich Plasma with that same attitude. They inject Platelet-Rich Plasma expecting the symptoms to go away.
That’s NOT what Platelet-Rich Plasma is for.
Platelet-Rich Plasma is a HEALING AGENT. It’s different. It’s not designed to eliminate symptoms like a drug. The only thing that PRP can do is use the body to heal itself.
So the first task, if you’re an orthopedic surgeon or someone treating a musculoskeletal issue, is to IDENTIFY precisely what’s producing the symptoms. This means looking at the connection between various muscles, tendons and ligaments. Understanding how they work in unison and finding out what’s causing stress in the system. All the muscles and ligaments and tendons are like different pieces of the puzzle – pulling weights in sync with their functions. So if there’s a anomaly in the whole picture, chances are one of the pieces of the puzzle is not able to carry out its job.
For an easy example, a tightness in the hamstring might be a result of a twisted ligament or bone in the back caused by a bad sitting posture. So in addition to injecting PRP to the hamstring, you might also need to inject to the ligament or bone on the back. And advise the patient to change posture.
This is the definition of Interventional Orthopedics.
And it requires extensive experience on the anatomy – AND delivering precise injections into the weaker links in the musculoskeletal system to improve overall function of the body. This means using image guidance technologies like fluoroscopy (Ultrasound guidance isn’t enough) to accurately place Platelet-Rich Plasma on areas which require healing. These type of injections enable efficient tissue regeneration and healing, and is usually not taught in medical school, residency, or fellowship.
That’s why we encourage physicians who’re offering PRP injections to get certified by taking one of the courses at the non-profit Interventional Orthopedics foundation.
Getting certified in Advanced Injection practices will make your Platelet-Rich Plasma results more consistent. There is a must-have for all physicians offering PRP Injections. It will also educate you on all the different ways regenerative medicine is being used right now.
6. Thinking only about relieving pain
We touched on it a little on the section above, but this is a broad topic that deserves an explanation on its own. Platelet-Rich Plasma as a healing tool is not something that you should make use of when your patients are in pain. Instead, PRP is used for a wide variety of issues that doesn’t involve pain including wound healing, skin aging reversal, wrinkle correction, dry eye syndrome, nerve regeneration, bone union, hair regeneration and even women’s fertility restoration and strengthening the uterus.
The bottom line is… Platelet-Rich Plasma isn’t just a tool for containing pain due to sports injuries. That days are far behind us now. Today, every physician, from the family physicians to neurologists and cardiologists, to fertility specialists and optometrists, to dermatologists and hair restoration experts… everyone uses Platelet-Rich Plasma.
Plus, more and more applications are discovered every day.
Platelet-Rich Plasma, on its own without funding by Big Pharma or the government, has become an integral part of modern medicine.
BONUS: The 7th Reason Why PRP Injections Fail
7. Super-concentration of Platelets
We know all analogies are imperfect but we like to use the expresso shot analogy when it comes to platelets. Platelets are like expresso shots for healing. But like expresso shots, your body can’t function using expresso shots alone. It needs food. That’s why studies like this one by Giusti has shown that super concentrating the Platelets may not only be useless, it can actually be harmful. What they did was completely isolate Platelets and platelets alone – and applied it in different concentrations on tendon cells to see if higher concentrations hurt or helped. That’s not Platelet-Rich Plasma. That’s just platelets.
And Platelets alone can’t do the job. In fact, it has nothing to support the survival of cells.
Instead, Platelet-Rich Plasma, is rich in Platelets while also including a small portion of RBC, WBC and the plasma serum which contains the nutrients the cells needed to survive.
That’s why research shows that taking the concentration above 1,000,000 platelets/µl doesn’t necessarily increase therapeutic benefits and as the Giusti study pointed out, it can actually have a detrimental effect.
This may not be an issue for the average physician, but it is possible to make this mistake thinking that higher concentration is better. That’s why we believe choosing the right Platelet-Rich Plasma kit plays an important role.
Because the kit has to produce Platelet-Rich Plasma in the ideal concentration – not just Platelets – so it can work every single time you administer it on patients.
Patent Application By Allan K Mishra
Speaking of the composition of Platelet-Rich Plasma, the famed Stanford researcher and Platelet-Rich Plasma pioneer Allan K. Mishra has recently filed a patent application titled “PLATELET RICH PLASMA FORMULATIONS” which can be found here. In it, Mishra claims he’s identified specific concentration of platelets, red blood cells, and white blood cells for treating treating connective tissue and/or cardiac tissue damage. It’s worth a look if you’re curious.
Add Regenerative Medicine to Your Practice
If you need help in getting started with Platelet-Rich Plasma, don’t hesitate to give us a call at (844) 377-7787 for a quick consultation. We can support you not only in supplying all the necessary equipment, but also provide you with the information you need to be a confident pioneer in this field. We’re looking forward to having you as part of our family.
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