Updates and Advances in Platelet Rich Plasma and Biocellular Prolotherapy

Donna Alderman, D.O. Medical Director, Hemwall Center or Orthopedic Re!enerative Medicine Co"Director, #nstitute or Biocellular Re!enerative Medicine

American Osteopathic Association o Prolotherapy Re!enerative Medicine, Con erence May $%&'

Overview o (ecture
&. Brie Overview o PRP $. #s PRP Prolotherapy a Place)o* +ideo '. ,ot all PRP is the same.
Concentration* Activation* RBCs, -BC.s*

/. #mportance o clarity when descri)in! PRP 0. Update on PRP studies and -orld Anti"Dopin! A!ency 1. Overview o Biocellular Prolotherapy
2 2 -hat it is, when to use it ,omenclature

3. Alderman"Ale4ander Protocol se5uence6 +ideo 7. Conclusion 8. 9uestions

2 PRP Prolotherapy, li:e De4trose Prolotherapy, stimulates musculos:eletal healin! )ut also provides !rowth actors to the tissue ;li:e addin! ertili<er=>

?@here is mountin! evidence that PRP may initiate, enhance, or accelerate healin! o connective tissue.A

Mishra, et al. ?Bports Medicine Applications o Platelet Rich PlasmaA, Current Pharmaceutical Biotechnolo!y, $%&$, &', &&70"&&80.

History o PRP
2 Cirst introduced &873 or use a ter open heart sur!ery to avoid donor trans usionD.machines were )i! thou!h= 2 &88%.s introduced oral and ma4illo acial sur!ery. 2 $%%1 introduced into Bports Medicine and Prolotherapy world when Mishra ;Btan ord> pu)lished paper on the success ul use o PRP or lateral epicondylitisE ;machines smaller, o ice si<e now> 2 $%%8 Heines -ard ;Pitts)ur!h Bteelers> reported usin! PRP or an inFured :nee Fust prior to the Bteelers winnin! the $%%8 Buper)owl.

#B PRP PRO(O@HGRAPH A P(ACGBO*

+#DGO CA, BG COU,D A@6 http6IIwww.prolotherapy.comIDo!.php

-HG, @O UBG PRP*

2 PRP is used when6 J-hen De4trose Prolotherapy stops )ein! e ective or levels outE J # de!eneration, discrete tear;s> or tendonosisE JPatient pre erence.

How wor:s in various ways

2 Platelets contain power ul !rowth actors which increase healin! and an!io!enesis. 2 Platelets also contain serotonin. -hen seratonin is released it promotes recruitment o neutrophils to the area which )oosts healin! and immunity . ;Duerschmied et al., Blood Kournal, Ce)ruary $%&'> 2 Gvidence that PRP cyto:ines and !rowth actors si!nal and recruit local repair ;mesenchymal> stem cells to the wound area, then help induce them to heal needed tissue.

adult mesenchymal stem ;repair> cells

activated platelets

Platelets adherin! to inFured tissue

#n vitro6 Cive old increase in Mesenchymal Btem Cell Lrowth with PRP

Mishra et al. ?Bu ered Platelet"Rich Plasma Gnhances Mesenchymal Btem Cell Proli eration and Chrondro!enic Di erentiationA, @issue Gn!ineerin!, &06 ;'> $%%8E p! /'&"/'0

Other thin!s to :now a)out PRP

2 PRP promotes di erentiation o tendon stem cells into active tenocytes ;Mhan! et al. $%&%> 2 Bhown to inhi)it in lammatory processes in osteoarthritis )y decreasin! a maFor pathway in the patho!enesis o OA ;,uclear actor :B > ;van Buul et al. Am K Bports Med, Au!ust $%&&> 2 Possi)le protective 5ualities on cells ;Ba)oldashti et al. $%&&> ;cultured human tenocytes protected rom de4amethasone and cipro lo4in> 2 N #ncreases via)ility o cells, used or many years in at trans er sur!ery ;A)u<eni and Ale4ander $%%&>

,ot all PRP is the same

CO,@RO+GRBH GO#B@B AB @O -H#CH #B BGB@D..

2 Concentration ;&.& to &%4>* 2 RBC content* 2 -BC content J amount and types* Dou)le spins* Better to use low or hi!her* 2 Activation* ;CaCl, e4o!enous throm)in> 2 Use o anticoa!ulant J citrate de4trose ;ACD> ma:es acidic J impact o ph* Bu er* 2 +arious classi ication systems

LG,GRA( DGC#,#@#O, o PRP

?Platelet Rich PlasmaA is autolo!ous )lood with concentrations o platelets a)ove )aseline levelsN, which contains at least seven !rowth actorsNN.A

@his de inition has )ecome too simple=

NHall, M. et al. Kournal o the American Academy o Orthopedic Bur!eons. $%%8E$361%$" 1%7. NNMar4, et al. Platelet rich plasma ;PRP>6 A Primer. Practical Pain mana!ement, March $%%7.

@raditional description o PRP ;sin!le spin>

,ormal Blood

Platelet Rich Plasma

Classic PRP6 Red cells !o down to 0P and -hite cells stay the same Mar4 and Lar!. Dental and Cranio ascial applications o Platelet Rich Plasma. 9uintessence Pu)lishin! Co., #nc. $%%0

Dou)le Bpin

PPP

(ess red (ess white

Bu y Coat ;-BC and Platelets> RBC and some heavier platelets

?H#LH"DG,B#@HA P(A@G(G@ R#CH P(ABMA

2 Hi!h"density platelet rich plasma ;HD"PRP> is de ined as autolo!ous )lood with concentrations o platelets at e5ual or !reater than our ;/> times circulatin! )aseline levels and which increases the important )ioactive protein load ;!rowth actors> in a direct correlative ashion.

2 2

Mar4, R., Qevy, B., Kaco)son, M. Platelet rich plasma ;PRP>6 A primer. Practical Pain Mana!ement, March $%%7. Hall, M., Ban:, P., Meislin, R., Ka<rawi, (., Cardone, D. Platelet"rich plasma6 Current concepts and application in sports medicine. Kournal o the American Academy o Orthopedic Bur!eons. $%%8E $361%$"1%7.

Reason why hi!h density thou!ht to )e important6 Mi!ration o repair cells ;mesenchymal stem cells> to inFury site increases with platelet concentration
7%% 3%%

,um)er o Human" Mesenchymal Btem Cells

1%% 0%% /%% '%% $%% &%% % BC D O (O B P PP &. $0 O $. 0 O 0 O

"""" #ncreasin! Platelet Concentration """"

$$3P increase in stem cell population with a 04 increase in plateletIprotein load

Haynesworth, BG, Bruder, BP, et alE ?Mito!enic Btimulation o Human Mesenchymal Btem Cells )y PRP Bu!!ests a Mechanism or Gnhancement o Bone RepairA, Presented at /7th Orthopaedic Research Bociety Meetin!, Dallas, @O, $%%$

#@.B A(( PRP BU@D.

2 -e need to )e more precise in how we descri)e it, need )etter classi ication systemE 2 Di erent concentrations and content seem to )e )etter or di erent tissues )ut studies vary.

-hite cells and in lammation**

2 #n lammation is how Prolotherapy wor:sD.so do we want to throw the )a)y out with the )athwater*

2 Bome cases may need more in lammatory PRP ;severe chronic tendonosis>. 2 However some cases may )ene it rom less in lammatory PRP, i.e. acute inFuries, muscle and intraarticular.

U,DGRB@A,D#,L @HG PROCGBB6 BOR@#,L OU@ @HG CO,CUB#O, Most systems separate )ased on wei!ht.
Decreasin! RBC.s decreases num)er o platelets so may have to use lar!er )lood volumes when reducin! Hct to !et same num)er o platelets. Also removes heavier plateletsDdoes this matter**

Platelets Bome platelets mi4ed in with -BC.s ;?)u y coatA> RBC.s ;and some heavier platelets>

$P HC@ 3P HC@

#ncreasin! HC@

BPOR@B MGD#C#,G C(ABB#C#CA@#O, BHB@GM OC P(A@G(G@ R#CH P(ABMA

?Mishra, et al. ?Bports Medicine Applications o Platelet Rich PlasmaA, Current Pharmaceutical Biotechnolo!y, $%&$, &', &&70"&&80.

Review o what was used in classic studies

2 &A6 #ncreased white cells, no activation, 0O or more6 ;more studies availa)le>
J Mishra study $%%1, e ective or chronic severe el)ow tendonosis J Pear)lossoms $ year study $%&$E si!ni icant improvement in pain and disa)ility in dou)le )lind randomi<ed controlled study or el)ow tendinopathy.

2 @ype /6 (ow or ,o -BC

J athletes under!oin! Achilles tendon repair recovered aster than control !roup ;Banche<, $%%3> " #ntraarticular :nee inFections showed si!ni icant improvement. ;Qon et al., $%&%> " @heori<ed in acute muscle inFury that low -BC may )e )etter )ecause o the already active supply o neutraphils there durin! inFury.;@oumi and Best, Br K Bports Med $%%'>

#n China6
2 ("PRP6 ?(eu:ocyte"PRPA J contains hi!h concentrations o platelets and leu:ocytes. Researchers in China show ("PRP helps with )one healin!, acute so t tissue wound healin!, and repair o acute muscle, tendon, li!ament, nerve and cartila!e inFury caused )y trauma.

Huan et al. ?Applications o leu:ocyte"and platelet"rich plasma ;("PRP> in trauma sur!ery.A Curr. Pharm Biotechnol. Kune $%&$E &';3>6&&3'"7/.

Other interestin! studies6

$%&'6 PRP proposed or use to prevent in ection in implant sur!ery
2 Achieved ?consistent antimicro)ial indin!s and stron! in vitro antimicro)ial properties a!ainst )acteria li:e methicilin"sensitive and methicillin" resistant Btaphyloccus aurea, Lroup A Btreptococcus and ,eisseria !onorrhoeae.A

2 (i and (i. PRP as a ,ew Approach to Prevent #n ection6 Preparation and #n +itro Antimicro)ial Properties o PRP. K +is G4p. April $%&'E 8;3/>.

Activation needed*
2 PRP can )e activated e4o!enously )y
J @hrom)in J ast, may ma:e unusa)le i too ast, not !enerally done with PRP Prolotherapy J Calcium chloride J slow, physiolo!ic, reverses anti" coa!ultant, re5uently done J Mechanical trauma" natural )yproduct o the inFection ;colla!en release rom tissue> Avoid activatin! too much ahead o time. ,inety percent o the pre a)ricated !rowth actors will )e released in the irst ten minutes

?PRP removed rom Prohi)ited (ist or $%&& a ter indin! current studies on platelet"derived preparations do not demonstrate a potential or per ormance enhancement )eyond a potential therapeutic e ect.A
http6IIwww.wada"ama.or!IenImedia" centerIarchivesIarticlesIwada"$%&&"prohi)ited"list" now"pu)lishedI

-hat is B#OCG((U(AR PRO(O@HGRAPH*

2 #nFection o autolo!ous adult stemIstromal cells rom adipose com)ined with PRP or BMAC ;)one marrow aspirate concentrate>, then inFected into inFured Foints or connective tissue to stimulate repair.

Remem)er How PRP wor:s

PRP !rowth actors si!nal locally availa)le adult stem cellsD..)ut si!nal is more li:e )luetooth than wi" i and i no locally availa)le stem cells availa)le then tissue repair will )e limited.
adult repair ;stem> cells
activated platelets

Platelets adherin! to inFured tissue

#mportant point to remem)er

2 ?Chronic in lammation uses up the local repair ;stem>cells.AN @his is

when we need to add repair cells to that area.

NQotaro Hoshimura, MD #nternational Cederation o Adipose @herapeutics ;#CA@B> Con erence, $%&&

MAKOR B#@GB OC ADU(@ MGBG,CHHMA( B@GM CG((B

AD#POBG @#BBUG and BO,G MARRO-

People don.t mind !ivin! up a little at

Cells can )e easily harvested rom the adipose tissue in si!ni icant num)ersE easy to processE low donor mor)idity

-#@H#, BO@H OC @HGBG BOURCGB is @HG MGBG,CHHMA( B@GM CG((

(i!ament @endon

$%&$ Btudy shows MBC.s secrete actors that inhi)it in lammatory processes in osteoarthritic synovium and cartila!e cultures.

2 +an Buul et al. Osteoarthritis Cartila!e. Oct $%&$ $%;&%>6 &&71"81.

2 AD and BM MBC.s undamentally di erent cell types )ut similar in action. 2 Beveral reports veri y there are more mesenchymal stem cells per unit volume in adipose tissue than in )one marrow ;up to 0%% to &%%% times as many > ;Mi<uno, $%%8E Craser, $%%1, Btern $%%0>.

2 AD may )e )etter or muscleIconnective tissue ;Adipose"derived stem cells orm unctional myotu)es via mechanical stimulation whereas )one"derived stem cells do notA, Gn!ler et al. University o Cali ornia, presented at $%&$ @GRM#B meetin!, Houston, @O>. 2 AD and BM MBC.s display same a)ility to di erentiate towards chondrocytes Iosteo)lasts ;,oel $%%7> althou!h some studies show BM )etter ;Pacini, et al. $%%3>.

-hen to use Biocellular Prolotherapy

2 -hen results rom PRP Prolotherapy have not achieved desired results or leveled outE 2 Moderate to severe de!enerative chan!es or discrete tear;s>E or 2 Patient pre erence.

Biocellular @erminolo!y
2 Adipose sample termed ?Adipose Derived"@issue Btromal +ascular CractionA ;AD"tB+C> 2 ?tissueA used to di erentiate rom re erences in the literature ;particularly rom la) papers> re erencin! Btromal +ascular Craction or ?cellular B+CA R cB+C which demands di!estion, etc.. 2 @ryin! to :eep audience clear we are tal:in! a)out non"manipulated tissues versus the isolatedI concentrates component parts

Clari ication more terminolo!y6 Adipose separation )elow.

Bupernatant ;lipid layer>

AD"tB+C

#n ranatant ;li5uidI)lood )ottom layer>

Alderman"Ale4ander Protocol
Pu)lished Kournal o Prolotherapy Au! $%&& Bince then many treatments done with hi!h success rate

Bet up ;sterile>

@U(#P PA@G,@GD M#CROCA,,U(A BHB@GM ?cell riendlyA. Disposa)les and reusea)les.

#n iltrator ;?multiportA>
Used to in iltrate area with local anesthetic

Harvestor
Used to harvest adipose tissue.

Kohnny (oc:6 allows syrin!e to )e held in a loc:ed position so that suction maintained or at harvestin!

#nFection Protocol
B@GP O,G6 Draw PRP or Bone Marrow B@GP @-O6 #,C#(@RA@#O, OC (OCA( A,GB@HGB#A ; luid !oes in> B@GP @HRGG PRG@U,,G(#,L ;to separate at> B@GP COUR6 HAR+GB@ CA@ B@GP COUR6 PRGPARG AD"tB+CIPRP or AD" tB+CIBMAC B@GP C#+G6 @RGA@MG,@ UB#,L U(@RABOU,D LU#DA,CG

,ot shown on +ideo6 Cirst6 Draw PRP, OR6 # doin! )one marrow do that. Gither one can then spin while doin! at harvest

OR6

BO,G MARRO-

CO,C(UB#O,
2 PRP and Biocellular Prolotherapy are increasin! in useE research and protocols are )ein! re ined and. 2 ,ot all PRP is the same. Di erent types appropriate or di erent pro)lems. More studies are needed. 2 Re!enerative Medicine is the wave o the uture.

9uestions**