As a distributor for the first commercial multicellular biologics system in Canada, our team at MDBiologix has over 20+ years of experience working with medical practitioners involved in the field of regenerative medicine. We support our partners with products and expertise that stand by emerging science in the field, which often means correcting common misconceptions about biologics.
And when it comes to PRP, there is one misconception that we hear more than any other.
What is it? Well, some practitioners still believe we don't understand why PRP works, that different preparations matter or that choosing the right type of PRP can make or break the success of your patients treatment.
This way of thinking is reminiscent of the early days of PRP therapy when practitioners understood very little about what components contributed to the healing potential of PRP and what applications most benefitted from this treatment option (1). They would use a single type of PRP unanimously across their clinical practice for any MSK injury and any successes or failures of their treatment was application-driven, rather than flaw in their preparation. The problem with this approach is it's like trying to use only a hammer to build an entire house.
The good news is that the year is 2021, and we now have over 20 years of research in PRP science that has resulted in a robust body of evidence to support specific PRP applications, and more importantly, which PRP preparations drive clinical favorable results (2). In sticking with the house analogy, the modern practitioner needs to leverage this new evidence and build a PRP toolbox with an assortment of tools (i.e. formulations) available depending on what will produce the best results.
The right tools for the job
So what exactly are the right tools when it comes to PRP? In 2018, Adrian Le and colleagues evaluated the published literature for randomized clinical trials using PRP and compiled the results across various popular applications to confirm what many other clinicians have reported anecdotally (2). Namely, that some preparations work better than others.
Before I go any further, it's important to recognize there are many different components to PRP and numerous classifications systems have been proposed. If you're interested in exploring all the components of PRP and how they influence the healing process, read our post here.
For the purposes of finding which PRP preparation is most effective, the best bang for your buck is going to be focusing on the blood cellular component and platelet concentration of PRP and how these influence outcomes across two key areas: Soft Tissue and Intra-articular Joint injections.
Soft Tissue Injections
The majority of research into soft tissue injections focuses on lateral epicondylitis (i.e. tennis elbow), however, there is plenty of evidence to support the use of PRP for patellar tendinopathy, plantar fasciitis, achilles and rotator cuff tendinopathy, among others. The same PRP formulation best practices apply broadly to applications within soft tissue pathologies.
In most instances, PRP formulations with white blood cells (LR-PRP) outperformed those without white blood cells (LP-PRP), which you can see in the table below (2). LP-PRP often resulted in no improvement over the control, which may suggest why some clinicians using these formulations don't achieve clinically significant results with PRP and will default back to conservative or surgical interventions.
Intra-articular Joint Injections
Regarding intra-articular joint injections, unsurprisingly, the vast majority of evidence explores degenerative joint diseases such as Osteoarthritis - specifically knee OA. Again, the same PRP formulation best practices can apply broadly across any pathology treated via intra-articular injections.
Unlike soft tissue injections, it appears that PRP formulations without white blood cells (LP-PRP) outperform those with (LR-PRP) as shown in the table below (2). This is likely due to LP-PRP having a reduced inflammatory profile when compared to LR-PRP, which clinicians have reported for many years makes this formulation superior for pain and mobility outcomes immediately and over several months post-injection.
Does platelet concentration still matter?
Now, I've spent a lot of time working with clinicians that are using, say, LP-PRP for intra-articular injections. However, they still aren't getting the results they're expecting. Or they are doing multiple injections before achieving any clinically significant result. More often than not, I find out that they are using a PRP system that does not produce highly concentrated PRP, which is a trend that we also find in exploring the above literature where the "correct" preparation of PRP fails to provide favourable results over control groups.
That's because the truly "correct" preparation of PRP needs to include a concentration of platelets that is at a minimum >4x above baseline (1). Seems like a no-brainer right? Well, many manufacturers of "me too" PRP equipment have spent a lot of money to refute this fact and deploy large sales teams to sell their inexpensive, ineffective, "PRP" systems.
To illustrate this problem, i'll reference a research paper by well-known orthobiologics practitioner Brian Cole and his team who treated 111 patients with symptomatic knee OA using LP-PRP. There widely reported results in the American Journal of Sports Medicine showed no difference between HA and PRP at any time point in their primary outcome measure (WOMAC) despite using LP-PRP (4). When looking into their methods of PRP preparation, it became clear that they were using Arthrex ACP system, which produces PRP that isn't even 2x above baseline concentration!
This is something that we see time and time again throughout the literature and in clinical practices where PRP results fall short of expectations. Don't fall into the trap of neglecting platelet concentration which may very well be the most important factor in achieving clinically significant results.
Bottom line and talking points for patients
This blog post isn't just for clinicians interested in building their regenerative medicine or orthobiologics practice. It's also for patients, who need to be informed about what they're paying for and what their clinician is offering to them. PRP is becoming an umbrella term for centrifugated blood, however, in order to achieve your desired treatment result you need to truly understand the composition of your PRP and tailor it to meet the needs of your patient.
That's why we represent the Harvest Terumo PRP system, which is a flexible platform for creating both LR-PRP and LP-PRP at a concentration (>5x baseline) that can produce clinically significant results as backed by scientific evidence.
References
Marx, RE. Platelet-Rich Plasma: Evidence to support its use. J Oral Maxillofac Surg 2004; 62:489-496.
Le A, Enweze L, DeBraun M, Dragoo J. Current Clinical Recommendations for Use of Platelet-Rich Plasma. Current Reviews in Musculoskeletal Medicine. 2018. 11. 10.1007/s12178-018-9527-7.
Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: from basic science to clinical applications. Am J Sports Med. 2009;37:2259–72.
Cole B, Karas V, Hussey K, Pilz K, Fortier L. Hyaluronic Acid Versus Platelet-Rich Plasma: A prospective, double-blind randomized controlled trial comparing clinical outcomes and effects on intra-articular biology for the treatment of knee OA. Am J Sports Medicine. 2017. 45(2):339-346.
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