Regenerative Treatments – PRP

Regenerative treatments for back and neck pain – platelet rich plasma (PRP)

 

Platelet rich plasma (PRP) injections have been around since the 1990s when they were used in maxilla-facial and plastic surgery. More recently, PRP injections have become popular for treating soft tissue injuries that can result in neck and back pain. Several elite athletes such as Tiger Woods and Rafael Nadal having undergone PRP treatment and some cite PRP injections as the reason for their speedy return to play after injury.

PRP injections work by stimulating healing in tendons, ligaments, muscles and joints through the activation of growth factors and reparative processes. This can then help to enhance function and reduce pain associated with soft tissue injuries and dysfunction.

The technique involves the use of a patient’s own blood, which is drawn and then centrifuged to separate the activated platelets. This platelet rich plasma is then injected into the area of tissue damage in order to stimulate repair. Ultrasound imaging may be used to help ensure that the injection reaches the intended site.

As the patient’s own blood is used there is no risk of rejection of foreign material, making PRP treatment a generally safe form of therapy.

This article will look more closely at the following issues regarding platelet rich plasma (PRP):

 

What are platelets, and what is PRP?

Platelets are an extremely important part of the blood and are involved in wound healing and clot formation. They contain natural growth factors such as platelet derived growth factor (PDGF), insulin like growth factor (IGF), vascular endothelial growth factor (VEGF), platelet derived angiogenic factor (PDAF), and transforming growth factor beta (TGF-ß). They also contain other substances that are important for wound healing, such as fibronectin.

regenerative therapy prp

Platelet rich plasma (PRP) is sometimes referred to as autologous platelet gel, plasma rich in growth factors (PRGF), or platelet concentrate (PC). PRP is created by collecting a patient’s blood and centrifuging it at varying speeds for around 12 minutes in order to separate it into three fractions: platelet poor plasma (PPP), (platelet rich plasma (PRP), and red blood cells.

A platelet activator (agonist) is then added to the PRP, typically in the form of bovine (cow) thrombin and 10% calcium chloride. This activates the clotting cascade and produces a platelet gel with a platelet concentration around 3-10 times that of ordinary plasma (Wang & Avila, 2007).

How does PRP work?

PRP is a source of numerous factors that are essential for healing, such as substances that enhance cell recruitment, multiplication and specialization. Specifically, PRP contains PDGF and epidermal growth factor, both of which are key to the synthesis of collagen and the activity of fibroblasts – essential elements in wound healing. Some research suggests that healing of soft tissue may be 2-3 times faster than normal in the presence of increased concentrations of these growth factors (Anitua et al., 2004).

PRP is considered by some to be a more comprehensive strategy to promote tissue regeneration, compared to the administration of single recombinant human growth factor. The substances found in PRP are thought to help speed up the growth of blood vessels to new tissues and enhance the creation of new scaffolding for bone and soft tissues, thereby supporting bone regeneration, wound healing, and cartilage repair.

What are the benefits of PRP?

PRP is relatively inexpensive and accessible as it is an autologous treatment.

PRP may be particularly useful in spinal fusion procedures as it has been seen to improve the ability to pack particulate graft materials, thereby helping to maintain space and support bone regeneration (Wang & Avila, 2007).

Some further potential advantages of PRP suggested by research include (Wang & Avila, 2007):

  • Improved graft adhesion
  • Reduction in micro-movement of graft
  • Accelerated wound healing, including epithelialization
  • Decreased scar formation
  • Increased osteoblast activity (osteoblasts are bone-building cells)
  • Angiogenesis (increased blood vessel growth).

Studies in humans are still insufficient to provide an accurate picture of the effects of PRP, but early studies have shown that treatment with PRP enhanced healing and bone regeneration (Anitua, 1999; Marx et al., 1998).

Is PRP safe?

Because PRP is derived from the patient themselves (an autologous treatment) it poses no risk of cross reactivity, disease transmission, or immune reaction, depending on the treatment protocol (Wang & Avila, 2007).

back-pain-injections-summer

However, the use of bovine thrombin as an activating agent for PRP could prompt a reaction by the immune system, in addition to making such treatments unsuitable for those who avoid cow-derived products (Landesberg et al., 1998).

PRP is a source of numerous growth factors, and while these are necessary for timely healing, they may also have a cancer-promoting effect. PRP injections work in part by increasing the initial inflammatory stage of healing, which could mean that a patient experiences a temporary increase in pain and swelling at the injection site. As such, patients are usually recommended to temporarily halt their use of anti-inflammatory medications in order to optimize results when undergoing PRP treatment.

In summary

Platelet rich plasma injections are a relatively new treatment for back and neck pain, with promising results seen in animal studies and in early trials in humans. These injections appear to work by triggering the body’s natural healing response, helping to repair damaged tissues such as ligaments, tendons, spinal discs, and bone that may be contributing to pain and dysfunction.

While further studies are needed, PRP injections may offer a cost-effective, relatively safe and accessible form of treatment for back and neck pain.

stem-cell-treatment-for-joint-pain

References

Anitua, E. (1999). Plasma rich in growth factors: preliminary results of use in the preparation of future sites for implants. Int J Oral Maxillofac Implants, 14:529–535.

Anitua, E., Andia, I., Ardanza, B., Nurden, P., Nurden, A.T. (2004). Autologous platelets as a source of proteins for healing and tissue regeneration. Thromb Haemost, 91:4–15.

Landesberg, R., Moses, M., Karpatkin, M. (1998). Risks of using platelet rich plasma gel. J Oral Maxillofac Surg, 56:1116–1117.

Marx, R.E., Carlson, E.R., Eichstaedt, R.M., Schimmele, S.R., Strauss, J.E., Georgeff, K.R. (1998). Platelet-rich plasma: Growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 85:638–646.

Wang, H-L., & Avila, G. (2007). Platelet Rich Plasma: Myth or Reality? Eur J Dent, Oct; 1(4): 192–194.

Dry Needling – an alternative treatment for chronic back pain

Dry needling

Dry needling is an increasingly popular treatment for relieving chronic back or neck pain caused by muscle tension and nerve dysfunction. This effective therapy is designed to create a local twitch response in the muscle in order to release muscle tension at the root of pain.

Dry needling treatment has very few potential side effects and involves the insertion of very thin needles through the skin into muscles, ligaments, tendons, subcutaneous fascia, and scar tissue. Dry needles may also be inserted near peripheral nerves, neurovascular bundles, or both so as to stimulate a response that can help with the management of neuromusculoskeletal pain.

Dry Needling Atlanta

The needle stimulates nociceptors or sensitive loci in the muscle or tissue to create a response that can disrupt dysfunctional neuromuscular activity. This may then help to relax the muscle and relieve associated pain.

Unlike with wet needling (used for corticosteroid injections, for example), the thin monofilament used for dry needling does not deliver any medication to the tissue.

Dry needling is sometimes defined as an intramuscular procedure targeting myofascial trigger points. However, treatment using dry needling may also target tissues other than muscles.

Trigger points and tender spots

Chronic neck and back pain can be a result of irritation in the muscles that causes tension and radiating pain. These trigger points or tender spots in skeletal muscle may be referred to as a ‘knot’ and can feel hard and uncomfortable.

Over time, chronic tension, muscle spasms, or cramps can cause irritation in other tissues as the body tries to compensate for the structural problem by altering posture or gait, for example. Ongoing muscle tension can cause pain directly, and may also contribute to changes in bones, ligaments, tendons, and spinal discs that also results in pain and other symptoms.

What can I expect from dry needling?

In a typical treatment session, a physical therapist will insert a number of dry needles into muscle and will leave them in place for 10 to 30 minutes. They will take note of any response from the muscle when inserting the needles and this will guide the insertion of additional needles to locate a trigger point or to better target problematic areas.

A number of studies have found evidence of immediate improvements in pain and disability following dry needling targeting myofascial trigger points. Typically, such treatments used ‘sparrow pecking’ or ‘pistoning’ techniques, i.e. rapid in-and-out needling to stimulate the tender point and provoke a neuromuscular response (Dunning et al., 2014). Further long-term trials are still needed to confirm these benefits and to demonstrate extended benefits of dry needling.

What conditions can dry needling treat?

Dry needling is used to address a variety of conditions, including musculoskeletal problems such as:

  • Acute and chronic injuries
  • Neck pain
  • Back pain
  • Sciatica
  • Knee and hip pain
  • Headaches
  • Tendinitis
  • Muscle Spasms and strains
  • Fibromyalgia
  • Tennis/Golfer’s Elbow
  • Repetitive strain injuries.

Dry needling vs. acupuncture

Although the tool of choice for both dry needling and acupuncture is the very thin, solid needle filament, dry needling is distinct from acupuncture.

Physical therapists who practice dry needling do so on the basis of modern knowledge of anatomy and neurology as discovered through scientific research into the nervous system and musculoskeletal system. Acupuncture was developed using a traditional knowledge base, largely the tenets of traditional Chinese medicine, and is underpinned by a particular philosophy.

Does dry needling hurt?

In most cases, patients undergoing dry needling do not feel the needle penetrate the skin and are only aware of the needle if it is inserted into a muscle that is tense. The resulting sensation can feel like an acute cramping of the muscle and it is this twitch response that helps to release the tension in the tissue and stimulate healing.

Dry needling for diagnosis

Dry needling may be a useful diagnostic tool, although further study is needed in this regard. The theory here is that if a patient with chronic back or neck pain has a powerful response to a needle in a particular spot, such as a familiar pain sensation, this can help to identify the location and cause of the pain.

When the needles are inserted into healthy muscle there is usually very little discomfort, helping the practitioner to go on to other areas so as to identify the tender spots.

What side effects can you expect with dry needling?

Dry needling is an effective and relatively safe treatment option for neck and back pain, with minimal risk of side effects. When adverse events do occur related to dry needling these usually take the form of mild soreness in the muscle and some minor bruising.

As always, it is essential to undergo treatment at a well-regarded facility which pays scrupulous attention to health and safety guidelines. The needles used for dry needling, as with acupuncture, are not reused for different patients and should be individually sealed and stored in sterile conditions prior to use, after which they should be disposed of in a safe manner to minimize the risk of infection.

Evidence for the effectiveness of dry needling

There is a growing body of evidence to support the use of Dry Needling Literature Review with Implications for Clinical Practice Guidelines DUNNING ET AL 2014(1)

In a case study reported in the International Journal of Sports and Physical Therapy, the use of dry needling led to significant relief of chronic low back pain in a 30-year-old woman on active military duty (Rainey, 2013). The patient had pain in her lower back and hip that started after a lumbar flexion injury while weight-training. The injury led to instability in her lower back (the lumbar spine) and her right hip and myofascial trigger points were identified in her right gluteus maximus and gluteus medius muscles.

The patient underwent two dry needling sessions to treat these muscles, along with intramuscular electrical stimulation (IES) and a home exercise program focusing on improving core stability.

The result of treatment was complete resolution of symptoms of lower back and hip pain, with the officer reporting no pain or disability at the follow-up appointment. The physical examination found no functional impairments or limitations, and spinal movement was normal. The researchers also noted the absence of myofascial trigger points, indicating no source of regional neuromusculoskeletal pain.

This therapy appears to help with pain management, reduces muscle tension and dysfunction and may help with electrical and biochemical dysfunction of the motor endplates, allowing the musculoskeletal system to function properly.

Dry needling may be particular useful, therefore, in helping patients with chronic neck or back pain to engage in other forms of rehabilitative therapy that are currently difficult because of muscle tension and pain.

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References

Dunning, J., Butts, R., Mourad, F., Young, I., Flannagan, S., Perreault, T. (2014). Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev, Aug;19(4):252-265.

Rainey, C.E. (2013). The use of trigger point dry needling and intramuscular electrical stimulation for a subject with chronic low back pain: a case report. Int J Sports Phys Ther, Apr;8(2):145-61.