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1. PRP for Chronic Pain Dr. John Hughes, DO February 21st, 2018

2. Dr. John Hughes, DO Doctor of Osteopathy 1)The body is a unit; one cannot treat a part of the body without considering its entirety. 2) Structure and function are reciprocally interrelated. 3)The body is capable of self-regulation, self-healing, and health maintenance. 4)The nervous system controls, influences, and integrates all bodily functions.

3. Learning Objectives • What causes chronic pain? • What is PRP? • How PRP treats chronic pain

4. But first, what is pain? • Pain results from tissue damage • It is a part of the body’s defense mechanism • Acute: intense and short-lived • Chronic: continuous and long-lived

5. What is Chronic Pain? •Starts with an injury or painful condition •Pain lasts 3-6 months or more •Can effect emotional and physical health

6. Chronic Pain Provokes •Changes in behavior •Fear-avoidance strategies •Physical atrophy

7. What Causes Chronic Pain? • Arthritis • Joint problems • Back pain • Headaches • Muscle strains and sprains • Repetitive stress injuries • Fibromyalgia • Nerve damage • Broken bones • Cancer • Acid reflux or ulcers • IBD or IBS • Endometriosis • Surgery • And more

8. Chronic Pain in the Body •Bombardment of the central nervous system (CNS) •Nociceptive impulses •Inflammation

9. 3Types of Pain Nociceptive Normal response to noxious insult or injury of tissues such as skin, muscles, visceral organs, joints, tendons, or bones Neuropathic Pain initiated or caused by a primary lesion or disease in the somatosensory nervous system Inflammatory Activation of an inflammatory cascade attempting to heal the injured area involving biochemical reactions

10. Nociceptive Inflammatory Physiology of Pain from Injury

11. Nociceptive • Triggers the nervous system to react • Can be overly sensitized = chronic pain Inflammatory Physiology of Pain from Injury

12. Nociceptive • Triggers the nervous system to react • Can be overly sensitized = chronic pain Inflammatory • Triggers biochemical reactions to heal the area • May not reach full healing potential = chronic pain Physiology of Pain from Injury

13. What happens when you strain your back? • Activation of nociceptive nerve fibers • A signal is sent down the neuron via the spinal cord to the brain • Signals upregulate the feeling of pain and initiates the inflammatory response 1) Nociception

14. What happens when you strain your back? • Damaged cells release cytokines and other mediators • Initiates vascular dilation and permeability • PMLs, followed by macrophages enter the scene • Stimulates the migration and proliferation of fibroblasts 2) Inflammatory Response

15. What happens when you strain your back? • Connective tissue begins to heal • Fibroblasts encourage synthesis of procollagen matrix (2-3 days after injury) • Vascular buds form increasing blood supply (3-4 days) 3) Proliferation Phase

16. What happens when you strain your back? • Collagen type I changes to collagen type III • Fibrils increase along lines of stress to become tightly packed (2-3 weeks) • Collagen thickens and increases to preinjury length but with only 50 to 70 % tensile strength • With severe injury, the healing process may stop before the tissue is sufficiently competent for everyday use 4) Remodeling Phase

17. Are Cortisone Injections the Answer? • Blocks inflammation • Stops the healing / inflammation cascade • Decreases immune function (risking microbial infection) • Causes tendon weakening, atrophy, or ruptures

18. Are Anti-Inflammatory Drugs the Answer? • Non-Steroidal Anti-Inflammatories (NSAIDS) • Inhibit COX enzymes and reduce the formation of prostaglandins • Damages the gastrointestinal track • Opiates • Block spontaneous firing fibres and nociceptive activity • Damages the body and brain • Cannabinoids • Inhibit peripheral sensitization • Blocks nociception

19. Other Treatments for Pain Surgery TENS PhysicalTherapy PsychologicalTreatment Acupuncture ChiropracticTreatment TherapeuticTouch / Reiki Nutritional Supplements Herbal Remedies Proliferative Injections …

20. Proliferative Injections • Proliferation: the growth or production of cells by multiplication of parts • Proliferative therapy: injection of irritant or proliferant solutions into the affected ligaments, tendons, and/or joints • Leads to local inflammation in the injected area • Localized inflammation triggers a wound healing cascade

21. PRP = The Supercharged Proliferative Injection

22. What is Platelet Rich Plasma (PRP)? • From autologous blood • Contains levels of platelets above baseline levels • Cell ratios in normal blood contain only 6% platelets, in PRP contains 94% platelets • Contains over 300 growth factors

23. Process of PRP 1) Collect blood 2) Separate the platelets 3) Extract platelet- rich plasma 4) Inject injured area with PRP

24. How Does PRPWork? 1) Formulates Collagen • The main component of connective tissue • Found in ligaments, tendons, skin, blood vessels, cartilage, and many other parts of the body • New collagen shrinks as it matures – tightening damaged tissue – making it stronger

25. • Regulates cell division and cell survival • Activates cellular proliferation and differentiation • Promotes cell growth • Functions as hormones-like regulator signals How Does PRPWork? 2) Releases Growth Factors

26. • Proteins released by cells • Lymphokine, monokine, chemokine, and interleukin • There are anti- and pro-inflammatory cytokines How Does PRPWork? 3) Secretes Cytokines

27. InjuriesTreatedbyPRP • Chronic Sports Injuries (ex.Tennis Elbow, AchillesTendonitis, and Runner’s Knee) • Degenerative Joint & Disc Disease • Chronic Sprains and Strains • Cervical,Thoracic, and Lumbar Spine Strains • Traumatic Brain injuries • Arthritic Joints • Shoulder Pain, Hip Pain, and Knee Pain • Ligament Laxity orTears • Tendon and Ligament Injuries • CarpalTunnel Syndrome

28. PRP HelpsTreat Unresponsive Chronic Pain & Injuries Over time, the body stops recognizing the area as something to repair PRP creates a purposeful, mild inflammation response to the damaged tissue This restarts the healing process and allows new fibers to grow back

29. PRP ReducesTendonitis Symptoms • 30 – 50% of all sports-related injuries are tendon disorders • 93% reduction of pain at the 2 year follow up • Achilles tendon or elbow, extensor or flexor tendonitis/tendonosis or tears • Collateral ligament tears

30. PRP Helps Decrease Osteoarthritis Symptoms • Restores hyaluronic acid concentrations • Improves angiogenesis • Reverses joint damage and stops disease progression

31. PRP Reduces Lower Back Pain • Treats structural ligaments (such as iliolumbar, sacroiliac, lumbosacral and supraspinous ligaments), muscle strains, and muscle fibrosis • Improve stability and dispersion of weight

32. Other Uses of PRP • Reversing hair loss • Facial rejuvenation

33. Celebrities for PRP Angelina Jolie: It has been reported that Angelina Jolie took the PRP skin rejuvenation treatment to boost her collagen. TigerWoods: In 2008,TigerWoods had a seriousACL injury. After reconstructionWoods received PRP injections to recover faster.And due to his speedy healing, 2009 was one the best years of his golfing career. Alex Rodriguez: TheYankees playerA-Rod had 5 PRP sessions after his hip surgery back in 2009. He was able to get back into shape for playing again way sooner than anticipated by his physician. Kobe Bryant: Kobe Bryant used to fly to Germany to heal his knee faster and avoid the threat of having to retire early.

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