Biologics and regenerative medicine as a form of treatment for the “master’s athlete”

Sports medicine societies, cardiologists and primary care physicians have recommended regular aerobic exercise for years with the rise of the obesity epidemic. At the same time we have seen the advent and development of the “master’s athlete” in endurance sports, which not only include running and triathlon, but team sports like ice hockey, ultimate frisbee and flag football. Paralleling the increasing life expectancy, athletes continue to compete and exercise regularly well into their 6^th, 7^th and 8^th decades of life in many sports. Whether chronic overuse or degenerative (arthritis), many of these master’s and fitness athletes will experience pain and injury that do not require surgical intervention. And while many of these injuries are treated with rest and physical therapy, the world of medical biologics can offer a level of more rapid soft tissue repair, pain relief and return to full function, without surgical intervention that often takes much longer and can be more costly to recover.

What are biologics and how are they used?

Biologics are medical therapies that can be injected or administered in such a way that tissue repair and remodeling is promoted. Examples include platelet rich plasma (PRP) and prolotherapy (concentrated dextrose, a sugar). While there are circumstances and injuries that may require surgery, sometimes biologics like PRP are used to enhance the surgically repaired tissue, such as repairing the meniscus.

Platelets contain growth factors that stimulate and promote tissue healing and repair.

PRP, as the name implies takes a patient’s own blood and spins it in a centrifuge. This concentrate the platelets in the layer of plasma at 2-8 times the starting concentration in the blood. Platelets contain growth factors that stimulate and promote tissue healing and repair. This solution of concentrated platelets can be injected back into the body with ultrasound-guidance, targeting an acute or chronic injury or source of pain. Depending on the injury and condition being treated, it may take a single procedure to treat (such as tennis elbow or chronic medial collateral ligament, MCL sprain or tear), or periodic injections every few years (as in the case of osteoarthritis). Even in the setting of arthritis, particularly middle age populations with osteoarthritis, this can be performed many times and prolong the need for total joint replacement.

Prolotherapy, using concentrated dextrose solution, is also pro-inflammatory, stimulating the intrinsic healing process to repair and remodel tissue. With ultrasound-guidance we can target the structure that is suspected as the cause of pain (chronic muscle strain, tendinitis, ligament sprain or joint inflammation, or nerve entrapment). With the ultimate goal being to stimulate tissue remodeling and repair, a small percentage of people (10-20%) will experience a few days of increased soreness or pain, followed by relief. The downside is that more than one injection or procedure may be needed to provide full relief of pain, sometimes taking up to six injections over a several-month period.

Advantages and disadvantages of PRP and prolotherapy

Pros of both prolotherapy and PRP:

• They are incredibly safe.
• They can be safely performed multiple times over the course of the lifetime.
• Can delay (arthritis) or prevent (ligament or soft tissue injury) the need for surgical intervention. The goal of these modalities is to prevent surgical intervention, which is possible in many cases.

Cons of prolotherapy and PRP include:

• Generally, they are not covered by insurance, as they are considered “experimental.” Sometimes worker’s compensation or a medical lien from car accident may cover, with authorization ahead of time.
• Thus, they increase out of pocket expenses and can be relatively expensive, particularly PRP.
  • PRP may only require a single injection to offer complete or extensive relief of pain and provide full function.
  • Prolotherapy, while not overly expensive for a single injection, could require multiple injections and thus add up over time.
  • Interested in learning more about prices? Call SPARCC to get an estimated cost at (520) 222-8076.
• While these injections are very well tolerated, following a prolotherapy injection there can be a brief 3-5 day period of increased soreness or pain starting the day after the procedure; not as common with PRP. Tylenol, ice and heat can be used for comfort and symptomatic treatment. Avoid the use of ibuprofen, Motrin, Aleve (NSAIDs) for this flared response.

Am I a good candidate for a biologic, PRP or prolotherapy?

PRP or prolotherapy can be helpful for most any condition. However, before investing in a procedure that is not covered by insurance, it can be helpful to consider diagnostic confirmation of the origin of pain. This can be achieved through a diagnostic injection, often with ultrasound-guidance, confirming that the pain is resolved with injection of a numbing medicine at the suspected location.

For example, a patient with arthritis of the knee would experience a significant relief of pain (for a 2-4 hour period) with the injection of lidocaine into the joint. Often physicians will offer to inject cortisone, which is covered by insurance and could offer longer-term relief, and could prevent the need for further intervention. However, if you are considering PRP or prolotherapy in the near future (within 6-8 weeks), then it would be advised to avoid cortisone, which would inhibit their effects.

You would like to consider PRP or prolotherapy. What is the next step?

The first step is to seek a consultation with an injection specialist who can evaluate the body part that is being considered for treatment, and confirm a biologic injection as an option. This also gives you the opportunity to establish rapport with the physician and build trust in their practice and skill.

Sometimes imaging is quite helpful to confirm a diagnosis and help direct the most appropriate treatment option with the best efficiency at resolving the problem. For your consultation, if you have already had imaging then plan to bring a copy/disc of images (not just a report) to the visit, or ask if your doctor has access to the images online.

Because both PRP and prolotherapy stimulate the inflammatory process to promote healing, you should plan to be off of any anti-inflammatory medications well in advance of a procedure. This will give you the best opportunity of only requiring a single procedure, or in the case of prolotherapy, the fewest number of injections. There is some debate about the duration of time off of NSAIDs or steroids, but most seem to agree that at least 10-14 days ahead of time is sufficient, but a month would be even better. Also, plan to not use these for at least 7-14 days after your procedure. Tylenol (acetaminophen) can be used after the injection for pain or soreness (or for those with routine headaches, not associated with the injection).

What should I plan for after PRP or prolotherapy?

Depending on the condition being treated, a brace or crutches may be necessary after the procedure. Often these are needed in the setting of soft tissue repair, perhaps treating a ligament tear or chronic sprain, promoting healing of the tissue and scar tissue formation, without the daily stress of joint movement.

Following either PRP or prolotherapy, a round of physical therapy can be necessary. First it promotes muscle balance to protect the affected joint or tissue, whether from arthritis or a muscle or tissue injury. Second, in the setting of a tendon or ligament injury, a progressive physical therapy program aids in the remodeling of scar tissue that forms at the site of injury to align itself with the fibers of the native soft tissue, increasing tensile strength to baseline level and function.

How soon can I return to my activity after PRP or prolotherapy?

Return to sport and full function is dependent on what procedure is performed, from PRP to prolotherapy, or even needling of the tissue. If there is tissue that needs to heal then more time may be required before returning to full physical activity. Full tissue healing can take 12-16 weeks, but often people are progressing back and are near full function well before this time frame. If tissue repair is not necessary, sometimes only a few days to weeks are needed to get people back to running, jumping and typical sporting activity. Again, your physician can guide the return to sport based on the purpose of the procedure.

Are there options beyond PRP and prolotherapy?

For some, PRP and prolotherapy will have maximized effect and benefit, sometimes only providing short-term pain relief. There are other options that could be considered, particularly if you experienced some benefit from PRP or prolotherapy. These options include autologous stem cell injection (the patient’s own bone or fat stem cells), amnionic stem cells (from amnionic fluid). Often these options are much more expensive because of the associated cost to harvest the stem cells.

There is not a lot of evidence to suggest that stem cells are absolutely superior to other forms of regenerative medicine, like PRP or prolotherapy. Much like PRP and prolotherapy, stem cell treatment in the setting of osteoarthritis is going to be most helpful before the patient has developed “bone on bone” joint spaces. In other words, when there is mild to moderate arthritis, we expect better results than once someone has severe arthritis.

At SPARCC we offer PRP, prolotherapy, and cortisone injections. Read more about PRP.

By Jon Minor, MD