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In the updated second edition of Free Yourself From Chronic Pain and Sports Injuries, PPM Editorial Advisory Board Member Donna D.
Alderman, DO, shares the fundamentals of how and why prolotherapy regenerative medicine works.
By Donna Alderman, DO (/author/2368/alderman)
Many people have heard the term “platelet-rich plasma” in news stories in connection with athletic injuries, however, not all may realize
that when platelet-rich plasma (PRP) is injected into and around a joint, it is actually a type of prolotherapy. In fact, PRP has been used
as a formula in prolotherapy since around 2005. The approach has been shown to be effective not only for older injuries but also for
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recent ones, making it ideal for athletic injuries. It has also successfully been used in the treatment of osteoarthritis (OA) and helpful for
cartilage repair.
Not All Platelet-Rich Plasma Is Equal
As the use of PRP has grown, so has the demand for, and availability of, PRP–concentrating machines and methods; several
manufacturers now make these systems. There are also doctors who “do it themselves” using a regular type of centrifuge rather than one
of the systems developed for this purpose. The basic differences among these various methods are: 1) the amount of concentration of
platelets (how many times a person’s normal levels (called “baseline” levels); and 2) the presence and number of red or white blood cells.1
Platelet Concentration
There is debate in the medical community about what is the best platelet concentration or cell type for different conditions; however,
most data supports a platelet concentration of four to six times a patient’s normal level (baseline) for most musculoskeletal
problems.2 More specifically, since the average normal patient’s platelet count is 250,0000 platelets per microliter, this means that the
magic number is 1.0 million to 1.5 million platelets per microliter (four to six times normal baseline). This concentration has shown better
tissue regeneration when compared to lower platelet concentrations. It also seems that much higher concentrations could have an
inhibitory effect,3 which may decrease effectiveness.4 Therefore, four to six times baseline has become the most commonly used
concentration for PRP, and this concentration range is known as “high-density.” Remember that platelets work by sending out
biochemical messages so that nearby available stem cells will come and help repair injured areas. It has been found that when high-
density PRP is used, there is a stronger stem-cell response when compared to whole blood or PRP with lower platelet concentrations.
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(https://www.practicalpainmanagement.com/sites/default/files/imagecache/lightbox-large/images/2018/05/31/CoverImage.png)
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Regenerative Medicine: Platelet-Rich Plasma and Stem Cell-Rich Prolotherapy for the Treatment of Musculoskeletal Pain 18/04/20 21.00
prolotherapy, both chronic and acute problems can be treated. Biocellular prolotherapy is especially well suited for sports injuries
because of its tendency to encourage repair using new, normal tissue rather than weaker scar tissue.
Adipose & PRP: Better Together
Studies have shown that using PRP and adipose tissue together “significantly improves” regeneration versus using adipose cells
alone.15 When adipose is used as the stem-cell source, PRP is thus typically used at the same time since this combination has been shown
to work synergistically in multiple studies.16 In one study, using adipose-derived cells with PRP versus PRP alone on Achilles tendon
injuries showed tendon strength for the adipose/platelet-rich plasma group to be greater, with a statistically higher production of
collagen and growth factors.17 Therefore, typically, adipose and PRP are done together during a biocellular procedure.
The Choice of Biocellular Formula: Adipose vs Bone Marrow
The choice of which stem-cell source to use in biocellular prolotherapy depends on several factors, including the condition being treated,
the age of the patient, the physician’s background and training, and the patient’s preference. While adipose and bone marrow formulas
have demonstrated similar treatment capabilities, there does appear to be functional differences between them. Some animal and
laboratory studies indicate that bone marrow may be preferred and more efficient for osteochondral (bone and cartilage)
regeneration.18 However, adipose has shown an excellent ability to stimulate cartilage regeneration,19 and there are many studies that
indicate similar chondrogenic (ability to make cartilage) potential between bone marrow-derived and adipose-derived mesenchymal stem
cells, or MSCs.20 In a recent case report, a patient received surgery for a cartilage defect, which is the traditional treatment.
This particular patient had a condition called osteochondritis dissecans and that treatment surgery failed. The patient then received an
injection of autologous adipose-derived MSCs into the area. The result was structural and functional improvement, as well as reduction of
pain level.21
In multiple studies, both adipose and bone marrow stem cells have shown the ability to change the microenvironment more favorably
toward healing and to decrease “bad” inflammation while promoting “good” inflammation and blood supply, helping to reduce pain and
stimulate repair. However, adipose is considered by some researchers to be better in this ability.22 There are also several advantages that
adipose has over bone marrow for ligament, tendon, and muscle repair,23 especially in certain joints. For these reasons, adipose is
becoming the preferred choice for connective tissue injury.
When to Use Stem Cell-Rich Prolotherapy: An Algorithm
Biocellular prolotherapy may be the preferable treatment for chronic or degenerative conditions where cellular depletion is suspected and
a more aggressive approach is needed or preferred.24 In many cases, prior to doing biocellular treatment, a clinician will recommend one
or two dextrose and/or PRP treatments to prime the area and see how much improvement can be obtained, and then advance to
biocellular if needed. The decision of which formula to use must be evaluated on a case-by-case basis, considering the problem to be
addressed, the particular injury site, and the person’s medical history—in addition to the individual’s age and health status. Only after a
thorough evaluation by a physician trained in these techniques, and an extensive discussion of a patient’s needs and expectations, can the
best decision be made to determine the optimal course of treatment. To get an idea of how a treatment plan is mapped out, see the Figure
below.
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(https://www.practicalpainmanagement.com/sites/default/files/imagecache/lightbox-
large/images/2018/05/29/Figure%201%20Prolotherapy.jpg)
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Addiction Medicine
Bracing/Splinting/Prosthesis
Complementary Treatments
Acupuncture
Biobehavioral
Homeopathy
Lasers
Magnets
Prolotherapy
Hormone Therapy
Interventional Pain Management
Manipulation and Massage
Nutraceutical
Pharmacological
Psychological
Rehabilitation
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