Platelet Rich Plasma (PRP) treatment for pain

[drpainfree]

anyone doing this for chronic pain? heard from my orthopod and sounds promising

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[bedrock]

It definitely has a role. Like any procedure, it's about selecting the right patient. If the problem is more psych or social than anatomical, don't expect much.

PRP can be very helpful for chronic tendinopathies, particularly when injecting with US guidance so the PRP is directed to the primary pathology seen on US.

The problem is there are a lot of quacks (DC, ND, and fringe MDs) out there with a needle doing general prolotherapy with a variety of substances on anything that hurts for whatever reason, and that often gets lumped in unfairly with PRP therapy.

 

[Ligament]

It definitely has a role. Like any procedure, it's about selecting the right patient. If the problem is more psych or social than anatomical, don't expect much.

PRP can be very helpful for chronic tendinopathies, particularly when injecting with US guidance so the PRP is directed to the primary pathology seen on US.

The problem is there are a lot of quacks (DC, ND, and fringe MDs) out there with a needle doing general prolotherapy with a variety of substances on anything that hurts for whatever reason, and that often gets lumped in unfairly with PRP therapy.

Agree. I have a patient getting PRP to the cervical spine by a chiropractor in Vancouver, BC! Need I say no image guidance involved?

 

[Aether2000]

Most insurers consider it investigational and will not pay for it.

 

[melancholy]

Some make a very good cash practice out of it. I agree that there are a ton of docs that market this stuff endlessly and use it with little regard for appropriate patient selection.

I would still say there are some conceptual similarities in terms of the overall goals of "prolotherapy" and PRP/ABI. Unfortunately, "prolo" does have a bad rap and thus the PRP folks don't want any sort of association with that word...

 

[lobelsteve]

Anything besides anecdotal reports?
All literature I've seen has been biased by author with interest.
Kind of like Jay Smith and US. (nothing wrong with it- but if all trigger point injections cannot be accurately placed in a cadaver without US, I know why- and not a shred of clinical outcome data).

Outcome data, yummm.

 

[Tenesma]

a few sports medicine practices that gear themselves towards anxious, young, healthy athletes have done VERY well with this... especially after the media reported several famous ball-players receiving it... they charge $600-$1,000 for treatments (cash) and get paid...

 

[caedmon]

Some people are doing intradiscal (PRP, autologous blood, chondrocytes) for discogenic pain. I know there are trials going on with PRP and Chondrocytes but they're in the earlier phases.

 

[Doctodd]

it has been discussed here before so u might find more info from searching on this forum or the physicians forum.

 

[drpainfree]

any articles to review?

 

[joshmir]

this shocked me the other day when our hand surgeon had a few cases booked for PRP injected for tennis elbow; seems it has to be booked in the OR, unsure why, and some rep comes in and spins the product down on the centrifuge...

 

[melancholy]

There's a foot/ankle ortho surgeon who books PRP for some of his ankle surgeries here.. not sure how long that's been going on.

 

[joshmir]

melancholy-

where are you a fellow?

 

[Gauss]

pubmed anyone?
AAOS is heavily into it: http://www.aaos.org/news/aaosnow/sep10/cover2.asp

Am J Sports Med. 2006 Nov;34(11):1774-8. Epub 2006 May 30.
Treatment of chronic elbow tendinosis with buffered platelet-rich plasma.

Mishra A, Pavelko T.

Department of Orthopedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, 1300 Crane Street, Menlo Park, CA 94025, USA. [email protected]
Abstract

BACKGROUND: Elbow epicondylar tendinosis is a common problem that usually resolves with nonoperative treatments. When these measures fail, however, patients are interested in an alternative to surgical intervention.

HYPOTHESIS: Treatment of chronic severe elbow tendinosis with buffered platelet-rich plasma will reduce pain and increase function in patients considering surgery for their problem.

STUDY DESIGN: Cohort study; Level of evidence, 2.

METHODS: One hundred forty patients with elbow epicondylar pain were evaluated in this study. All these patients were initially given a standardized physical therapy protocol and a variety of other nonoperative treatments. Twenty of these patients had significant persistent pain for a mean of 15 months (mean, 82 of 100; range, 60-100 of 100 on a visual analog pain scale), despite these interventions. All patients were considering surgery. This cohort of patients who had failed nonoperative treatment was then given either a single percutaneous injection of platelet-rich plasma (active group, n = 15) or bupivacaine (control group, n = 5).

RESULTS: Eight weeks after the treatment, the platelet-rich plasma patients noted 60% improvement in their visual analog pain scores versus 16% improvement in control patients (P =.001). Sixty percent (3 of 5) of the control subjects withdrew or sought other treatments after the 8-week period, preventing further direct analysis. Therefore, only the patients treated with platelet-rich plasma were available for continued evaluation. At 6 months, the patients treated with platelet-rich plasma noted 81% improvement in their visual analog pain scores (P =.0001). At final follow-up (mean, 25.6 months; range, 12-38 months), the platelet-rich plasma patients reported 93% reduction in pain compared with before the treatment (P <.0001).

CONCLUSION: Treatment of patients with chronic elbow tendinosis with buffered platelet-rich plasma reduced pain significantly in this pilot investigation. Further evaluation of this novel treatment is warranted. Finally, platelet-rich plasma should be considered before surgical intervention.

 

[lobelsteve]

Alan is a nice guy. But he also owns the PRP patents, process, equipment.
Funny aaos for PRP but against Vertebroplasty.

 

[bedrock]

PRP is a lot less risky than elbow surgery......or vertebroplasty.

 

[ParaVert]

So to resurrect this thread,

dePuy rep at the hospital today, inservicing staff on PRP for knee/hip arthroplasty. Asked him to come by, talked with him about injections. He didn't know much but is putting me in contact with his associate.

Anybody doing? Anybody getting paid? Procedure codes? Sounds pretty good from a modality standpoint, but is it profitable in an office-based practice or even a hospital-based practice?

 

[murphles]

Am J Sports Med. 2010 Feb;38(2):255-62.
Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up.
Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T.
SourceDepartment of Orthopaedic Surgery, HAGA Hospital, The Hague, Netherlands.

Abstract
BACKGROUND: Platelet-rich plasma (PRP) has shown to be a general stimulation for repair. Purpose To determine the effectiveness of PRP compared with corticosteroid injections in patients with chronic lateral epicondylitis.

STUDY DESIGN: Randomized controlled trial; Level of evidence, 1.

PATIENTS: The trial was conducted in 2 teaching hospitals in the Netherlands. One hundred patients with chronic lateral epicondylitis were randomly assigned in the PRP group (n = 51) or the corticosteroid group (n = 49). A central computer system carried out randomization and allocation to the trial group. Patients were randomized to receive either a corticosteroid injection or an autologous platelet concentrate injection through a peppering technique. The primary analysis included visual analog scores and DASH Outcome Measure scores (DASH: Disabilities of the Arm, Shoulder, and Hand).

RESULTS: Successful treatment was defined as more than a 25% reduction in visual analog score or DASH score without a reintervention after 1 year. The results showed that, according to the visual analog scores, 24 of the 49 patients (49%) in the corticosteroid group and 37 of the 51 patients (73%) in the PRP group were successful, which was significantly different (P <.001). Furthermore, according to the DASH scores, 25 of the 49 patients (51%) in the corticosteroid group and 37 of the 51 patients (73%) in the PRP group were successful, which was also significantly different (P = .005). The corticosteroid group was better initially and then declined, whereas the PRP group progressively improved.

CONCLUSION: Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and significantly increases function, exceeding the effect of corticosteroid injection. Future decisions for application of the PRP for lateral epicondylitis should be confirmed by further follow-up from this trial and should take into account possible costs and harms as well as benefits.

 

[murphles]

I actually am getting paid in some cases for this. Tendinosis does not have a lot of options. Patients seem happy to have an option. Following my carefully selected patients for outcomes-so far they are doing really well. We'll see.

 

[Gauss]

It's a Category III CPT code 0232T for all services, you cannot bill Mcare separately for venipuncture, injection code, guidance, etc.

 

[Ligament]

I'm doing a decent amount of PRP. Insurance is not paying unfortunately. Results are promising so far.

 

[bedrock]

I'm doing a decent amount of PRP. Insurance is not paying unfortunately. Results are promising so far.

What have you been using it for?

 

[ParaVert]

and more importantly, where did you find patients willing to pay for it???

 

[Ligament]

and more importantly, where did you find patients willing to pay for it???

Lots of folks in the northwest interested in "natural" methods of pain control. I always offer these folks the full range of options; steroids, viscosupplementation, nerve ablation, prolotherapy, PRP. Every single PRP patient thus far has failed lots of conventional therapy.

 

[Ligament]

What have you been using it for?

Ligament, tendon, and cartilaginous injuries that have failed conventional therapy. I've honestly been surprised how well it has been working. Always use image guidance, always do tenotomy where applicable.

Jury is still out on long term benefit in my practice but so far promising!

 

[joshmir]

do you have a rep come in and spin it down for you on their equipment? how are getting your PRP to inject?

thanks for sharing your success

 

[lobelsteve]

When I do PRP they have failed steroid injection, PT, hybresis, TENS.

10 min in centrifuge. 2 vials of 4cc whole blood in purple top.

We draw off the buffy coat and some plasma, leave the red cells.

Inject through a 27G.

Depending on site it bills as a trigger point or tendon injection.

 

[Ligament]

do you have a rep come in and spin it down for you on their equipment? how are getting your PRP to inject?

thanks for sharing your success

Hi joshmir, yes I have a perfusionist company come in to draw the blood and spin it down on their equipment. Frees up my staff and they are very good.

If you have the staff, best way is to do it yourself. I'm trying to keep overhead very low.

 

[sblau001]

I have a friend up in NY and CT who is doing a lot of PRP and being reimbursed by some of the local insurance carriers. I tried to start up PRP in my practice as well but unfortunately it's not covered by any insurance companies where I practice. The problem is that the kits themselves are quite pricey, anywhere from $150-300. Sampson in California came out with an article recently in Archives of PMR describing its use in knee OA. I have seen excellent long lasting results so far in my own patients with moderate OA treated with PRP who did not respond well first with steroid injections.
My personal take on PRP is that there may be a lot of promise, especially for chronic tendon/ligament/meniscal injuries. Injecting these areas with steroids decreases healing, when what you really want to be doing is promoting a healing response. That being said, if you're looking for stone cold hard data, up to date the studies have been very small in number, not well case-controlled, with somewhat mixed results. For example, while studies performed by physiatrists almost always tend to show great results, an orthopedic association recently reviewed a bunch of studies and formally recommended against its use. (Hmmm... secondary gain?)

 

[Ligament]

For example, while studies performed by physiatrists almost always tend to show great results, an orthopedic association recently reviewed a bunch of studies and formally recommended against its use. (Hmmm... secondary gain?)

Yes. The orthopods did the same thing damning vertebroplasty but not kyphoplasty. Guess which procedure orthopods tend to do?

 

[drf]

When I do PRP they have failed steroid injection, PT, hybresis, TENS.

10 min in centrifuge. 2 vials of 4cc whole blood in purple top.

We draw off the buffy coat and some plasma, leave the red cells.

Inject through a 27G.

Depending on site it bills as a trigger point or tendon injection.

Can you describe mechanistically how you inject PRP as compared to how you inject a steroid?

 

[lobelsteve]

Can you describe mechanistically how you inject PRP as compared to how you inject a steroid?

Pmt for either.

 

[epidural man]

Let me just hijack this thread for a second...

So let me get this straight....

So using ultrasound for certain injections (caudal, targeted cervical diagnostic nerve blocks, stellate ganglion blocks) is considered money grubbing and immoral and akin to murder.....and using pulsed radio frequency to various DRG's and nerves is considered voodoo medicine and akin to witchcraft,

yet you are all perfectly fine with platelet rich plasma treatment?

I just wanted to make sure.

😎

 

[lobelsteve]

Let me just hijack this thread for a second...

So let me get this straight....

So using ultrasound for certain injections (caudal, targeted cervical diagnostic nerve blocks, stellate ganglion blocks) is considered money grubbing and immoral and akin to murder.....and using pulsed radio frequency to various DRG's and nerves is considered voodoo medicine and akin to witchcraft,

yet you are all perfectly fine with platelet rich plasma treatment?

I just wanted to make sure.

😎

PRP in my office is a trigger point injection. It is free to remove and spin blood when I am doing it. Stop by, I'll spin your blood. US adds significant cost to medicine with very limited proven benefit for shoulders, and no proven outcome data for many of its intended uses. Pulsed RF is always voodoo but has some basic science as far as chemical effect on the axon that is proven. No idea how this translates to clinical outcomes. I use PRF when I am too chickensht to thermal lesion a nerve.

 

[ampaphb]

Let me just hijack this thread for a second...

So let me get this straight....

So using ultrasound for certain injections (caudal, targeted cervical diagnostic nerve blocks, stellate ganglion blocks) is considered money grubbing and immoral and akin to murder.....and using pulsed radio frequency to various DRG's and nerves is considered voodoo medicine and akin to witchcraft,

yet you are all perfectly fine with platelet rich plasma treatment?

I just wanted to make sure.

😎

I do some of the voodoo and witchcraft you mentioned, but I do it after TELLING the patients there is no data to back up what we are about to do.

You will notice that the study cited for epicondylitis is an RCT. Do you have similar quality studies for the procedures you are advocating?

 

[epidural man]

You will notice that the study cited for epicondylitis is an RCT. Do you have similar quality studies for the procedures you are advocating?

yep

 

[epidural man]

I do some of the voodoo and witchcraft you mentioned, but I do it after TELLING the patients there is no data to back up what we are about to do.

You will notice that the study cited for epicondylitis is an RCT. Do you have similar quality studies for the procedures you are advocating?

By the way, observational studies are also evidence, albeit lower quality - but still evidence. Lots of observational studies on pulsed on many different things showing efficacy.

I don't recall them ever using the word Voodoo in their discussion, although I can double check.

Also, lack of data does in no way mean lack of efficacy.

 

[epidural man]

I use PRF when I am too chickensht to thermal lesion a nerve.

Yep, me too. Which is most a lot of the time for what I am using it for.

I hear people doing high temp to the DRG. I don't dare. Sympathetic chains and gangions - I'm a little scared of that too.

I used to do high temp to the TON, but then had some severe alloynic patients afterword - they were miserable.

Now just pulse the TON.

 

[SSdoc33]

epidural man, i really dont have a vendetta against you, but i categorically disagree with every post and every opinion that you have. i find your posts somewhat disturbing. i can't be more specific, because i find them ALL to be disturbing.

 

[ampaphb]

epidural man, i really dont have a vendetta against you, but i categorically disagree with every post and every opinion that you have. i find your posts somewhat disturbing. i can't be more specific, because i find them ALL to be disturbing.

I was giving him the benefit of the doubt, SSdoc, but am rapidly concluding that ... :troll:

 

[epidural man]

epidural man, i really dont have a vendetta against you, but i categorically disagree with every post and every opinion that you have. i find your posts somewhat disturbing. i can't be more specific, because i find them ALL to be disturbing.

Well that certainly says a lot.

Let's review the last few posts from reverse order - since those are apparently disturbing.

Lovelsteve mentions he uses pulsed when he is too scared to use high temp - I agreed. (you find this disturbing, I find that telling, and good luck with high temp to the TON) I find it VERY weird that you would disagree that I won't use high temp to the DRG - seriously.

Next I mention that observational studies are evidence. By the way, you think I make this **** up? There has been brilliant minds that write a ton of stuff about this - look up some things Bogduk and others have written about why in pain, we NEED to use high quality observational studies because often RCT's can't or will never be done. I don't know what else to say to this. And If you think that lack of evidence is the same as negative evidence...well, I'm getting more flabergasted here.

Next, i comment that there is a well controlled RCT that shows that pulsed works. I can continue to post articles, but come on, I think you all know how to use google as well. I'll give you a great start - Cohen recently did an editorial on pulsed RF, and Sluitjer did as well. Both of them summarize nicely the recent evidence to pulsed.

Then my first post - I tongue and check make a comparison to PRP and other modalities that I have mentioned (and got flamed) to make a small point of irony. I'm sorry you don't have a sense of humor.

Now lets move to another thread that I recently posted on. The subject was particulate steroid, and the theme had evolved to cervical TFESI - I mentioned that some of the reports of devastating disasters have been from direct needle trauma. I also mention that I am not sure that any of the case reports were done with DSA. Please specify how anyone could disagree with this - OTHER than find literature to answer the question I pose.

In this same thread, I was asked to provide a reference to something I mentioned - I did better, I provided the document. Not sure how you could disagree with this, but I haven't walked in your shoes.

Next, based on my mentioning of DSA, the question was posed, can you cannulate a vessel and miss it on DSA? I think that is a great question, gave my response saying so, and try to solicit some discussion on sensitivity of DSA, 'cuz I don't know the answer. It confuses me again that you would find that disturbing.

I can go on...i'll stop for now.

I would say this. If you find these posts "disturbing", you may want to keep that to yourself, because it says something about you to spew that kind of blackness and poison. I'm not sure you are filled with that, I hope for your patient's sake you are not. I will, however, give you the benefit of the doubt on that.

Finally, rather than say something so d*ckheadish, post some evidence, post an article, give an example. Show me some data that some Cervical TFESI that caused a stroke or death was done with DSA. Post an article that shows that high temp to the DRG works well. I'll give you a head start - that guy in Brigham's in Boston who's name I can't spell has written some on this - something like Semophelous or whatever. Give an example or case report about how ultrasound is ridiculous to use in the neck.

Be a force for good my friend. Start making the world a better place. It isn't too late to start being a better person.

 

[epidural man]

epidural man, i really dont have a vendetta against you, but i categorically disagree with every post and every opinion that you have. i find your posts somewhat disturbing. i can't be more specific, because i find them ALL to be disturbing.

Oh and one more thing,

I rarely come up with an original thought anyway. Most of what I post here is a regurgitation of something I have read in the literature or a book of some sort.

The fact that you categorically disagree with all of that....that is a disturbing fact as well, don't you think?

 

[101N]

Oh and one more thing,

I rarely come up with an original thought anyway. Most of what I post here is a regurgitation of something I have read in the literature or a book of some sort.

The fact that you categorically disagree with all of that....that is a disturbing fact as well, don't you think?

Dude:

You know how to read?

 

[epidural man]

Dude:

You know how to read?

barely....

I certainly can't spell.

 

[SSdoc33]

you are misinterpretating data all over the place. doesnt matter if you post an article, then glean whatever sliver of info that supports your claims.

lets summarize what you have advocated for in the last few weeks:

1. caudal epidurals under ultrasound
2. cervical "selective" nerve root blocks and (gulp) stellate ganglion blocks under ultrasound
3. pulsed RF of.... seemingly everything
4. L2 SNRB for discogenic pain
5. the ability of offering some sort of injection to nearly all of your patients
6. the UNDERdiagnosis of discogenic pain from MRIs.

these are outside of the standard of care, and the reason for my angst. you are easily > 2 st. dev's from the mean. i may be a A-hole, but I know what I'm doing and I'm not a cowboy. By my "dickheadish" posts, I believe I am making the world a better place. Maybe at least try to get you to understand how outside of the norm you are.

 

[101N]

you are misinterpretating data all over the place. Doesnt matter if you post an article, then glean whatever sliver of info that supports your claims.

Lets summarize what you have advocated for in the last few weeks:

1. Caudal epidurals under ultrasound
2. Cervical "selective" nerve root blocks and (gulp) stellate ganglion blocks under ultrasound
3. Pulsed rf of.... Seemingly everything
4. L2 snrb for discogenic pain
5. The ability of offering some sort of injection to nearly all of your patients
6. The underdiagnosis of discogenic pain from mris.

These are outside of the standard of care, and the reason for my angst. You are easily > 2 st. Dev's from the mean. I may be a a-hole, but i know what i'm doing and i'm not a cowboy. I don't know you from adam, but i hope your patients agree that you are as good as you think you are....

1+

 

[Tenesma]

intellectually I have a big problem with almost everything we do in the field of pain medicine due to the crappy literature and poor studies - and the fact that so much of our outcomes are blurred by significant psycho-social morbidities....

so intellectually, I agree with SSdoc33 re: epiduralman... i just don't agree w/ SSdocs political views.

However, on the flip-side --- epiduralman is probably seeing all of the same difficult patients that we all see... These are the patients that surgeons don't want to/can't touch. These are the patients who have failed multiple treatment modalities. These are the patients who have exhausted several previous pain docs... and they are now in your lap. Options?
1) Refer them to the university hospital - where (odds are) they won't get much better care
2) Tell them to suck it up, learn to live with their pain, and to do stretches at home and try to enroll them in some type of CBT
3) Or pursue a variety of experimental procedures - with the high likelihood that most will be ineffective, or will give very short term relief.

So i can't blame epiduralman for at least trying other modalities - because we are all stuck in similar predicaments of wanting to help our patients.

But here is where epiduralman is actually feeding into the problem.

Patients seek cures and fixes - they have this mentality that their chronic problem isn't actually a chronic condition, but rather an ongoing acute condition that just needs a diagnosis and a definitive treatment. Every time you offer them a procedure, what are they going to say? NO? of course not. they are willing to try anything, because they really believe that this is the next cure...

 

[101N]

intellectually I have a big problem with almost everything we do in the field of pain medicine due to the crappy literature and poor studies - and the fact that so much of our outcomes are blurred by significant psycho-social morbidities....

so intellectually, I agree with SSdoc33 re: epiduralman... i just don't agree w/ SSdocs political views.

However, on the flip-side --- epiduralman is probably seeing all of the same difficult patients that we all see... These are the patients that surgeons don't want to/can't touch. These are the patients who have failed multiple treatment modalities. These are the patients who have exhausted several previous pain docs... and they are now in your lap. Options?
1) Refer them to the university hospital - where (odds are) they won't get much better care
2) Tell them to suck it up, learn to live with their pain, and to do stretches at home and try to enroll them in some type of CBT
3) Or pursue a variety of experimental procedures - with the high likelihood that most will be ineffective, or will give very short term relief.

So i can't blame epiduralman for at least trying other modalities - because we are all stuck in similar predicaments of wanting to help our patients.

But here is where epiduralman is actually feeding into the problem.

Patients seek cures and fixes - they have this mentality that their chronic problem isn't actually a chronic condition, but rather an ongoing acute condition that just needs a diagnosis and a definitive treatment. Every time you offer them a procedure, what are they going to say? NO? of course not. they are willing to try anything, because they really believe that this is the next cure...

If what you are saying is that the problem with pain medicine is that it's 'palliative' rather than rehabilitative, then I couldn't agree more.

IMO, about two thirds of our patients have a primary diagnosis of poor coping. Procedures only make that condition worse.

 

[epidural man]

you are misinterpretating data all over the place. doesnt matter if you post an article, then glean whatever sliver of info that supports your claims.

lets summarize what you have advocated for in the last few weeks:

1. caudal epidurals under ultrasound
2. cervical "selective" nerve root blocks and (gulp) stellate ganglion blocks under ultrasound
3. pulsed RF of.... seemingly everything
4. L2 SNRB for discogenic pain
5. the ability of offering some sort of injection to nearly all of your patients
6. the UNDERdiagnosis of discogenic pain from MRIs.

these are outside of the standard of care, and the reason for my angst. you are easily > 2 st. dev's from the mean. i may be a A-hole, but I know what I'm doing and I'm not a cowboy. By my "dickheadish" posts, I believe I am making the world a better place. Maybe at least try to get you to understand how outside of the norm you are.

you are so right. you have my apologies.

 

[bedrock]

If what you are saying is that the problem with pain medicine is that it's 'palliative' rather than rehabilitative, then I couldn't agree more.

IMO, about two thirds of our patients have a primary diagnosis of poor coping. Procedures only make that condition worse.

It's a balancing act, but an important part of every eval and follow-up.
Setting appropriate expectations, particularly the understanding that most of our treatments reduce but do not cure pain.

One of the most important parts of our job is discuss with patients the hard, honest reality of their chronic pain issue, because they haven't been told that by their surgeon, family doc, or alternative medicine shaman, who led them on to believe that the "next" treatment would make them 17 again.

It's also one of the hardest things for physicians to ever admit to themselves or to patients "There is nothing else we can do for you"...................and endless procedures distort that important message.