Summarizing the latest Meta-Analysis for Platelet-Rich Plasma (PRP) DOSING Across several Musculoskeletal (MSK) Conditions

General Observations

• Platelet dosage and injection volume appear to influence treatment outcomes across different conditions

• Optimal dosage and volume may vary depending on the specific musculoskeletal condition

• Further research is needed to establish definitive guidelines for each condition

Condition-Specific PRP Usage

Knee Osteoarthritis (OA)

• Platelet Dose: Studies show positive outcomes with doses ranging from 5 billion to over 12 billion platelets

• Volume: Typically 3-8 mL per injection

• Notes:

• Some studies suggest better outcomes with doses exceeding 10 billion platelets

• Multi-injection protocols have shown promise in some cases

Hip Osteoarthritis

• Platelet Dose: Positive outcomes noted with a minimum of 3.5 billion platelets

• Volume: Generally 4-8 mL per injection

• Notes: Some studies report improved results with doses exceeding 10 billion platelets

Rotator Cuff Tendinopathy

• Platelet Dose: Studies have used doses ranging from less than 5 billion to almost 16 billion platelets

• Volume: Typically 3-6 mL per injection

• Notes: One study using 16 billion platelets (administered over 4 injections) showed improved pain and functional scores

Lateral Epicondylopathy (Tennis Elbow): LEVEL 1 EVIDENCE

• Platelet Dose: Positive outcomes reported with doses ranging from 2.5 to 9.5 billion platelets

• Volume: Usually 2-3 mL per injection

• Notes: Some protocols use multiple small-volume injections

Gluteal Tendinopathy

• Platelet Dose: Patient-reported outcomes improved with doses between 5-10 billion platelets

• Volume: Generally 4-6 mL per injection

• Notes: Volume may be adjusted based on the specific area of tendinopathy

Glenohumeral Osteoarthritis

• Platelet Dose: Limited studies, but doses typically range from 4-8 billion platelets

• Volume: Usually 4-6 mL per injection

• Notes: Treatment often combined with physical therapy for optimal results

Carpometacarpal Osteoarthritis

• Platelet Dose: Studies have used doses ranging from 2-5 billion platelets

• Volume: Typically 1-2 mL per injection

• Notes: Smaller joints require lower volumes; multiple injections may be necessary

Carpal Tunnel Syndrome

• Platelet Dose: Limited studies, but doses typically range from 3-6 billion platelets

• Volume: Usually 1-3 mL per injection

• Notes: Ultrasound guidance often used for precise placement

Ankle Osteochondral Defect

• Platelet Dose: Studies have used doses ranging from 5-10 billion platelets

• Volume: Generally 2-4 mL per injection

• Notes: Often combined with surgical interventions for optimal outcomes

Key Considerations

1. Dosage Variability: The optimal platelet dose may differ across conditions and individual patients

2. Injection Volume: Injection volumes typically range from 1-8 mL, but may vary based on the specific condition, treatment protocol, and anatomical considerations

3. Injection Frequency: Some conditions may benefit from single high-dose injections, while others may require multiple injections of lower doses

4. Individual Response: Patient factors such as age, severity of condition, and overall health may influence PRP effectiveness

5. Preparation Method: The specific PRP preparation technique can affect both platelet concentration and final injection volume

6. Anatomical Considerations: Smaller joints and structures generally require lower volumes and potentially lower platelet doses

Summary

PRP therapy shows promise for various musculoskeletal conditions, including different types of osteoarthritis, tendinopathies, and specific spine pathologies. While there’s a well founded trend suggesting that higher platelet doses (generally above 5 billion platelets) may lead to better outcomes, the optimal dose and volume can vary significantly by condition and anatomical location. 

This meta-analysis provided a great synthesis of injection volumes and doses. Injection volumes typically range from 1-8 mL, with larger joints like the knee and hip often receiving higher volumes (3-8 mL) compared to smaller targets like the carpometacarpal (CMC) joint or carpal tunnel (1-3 mL). The volume used may also depend on the specific pathology and the area being treated. Other than a handful of studies showing a doubling of the platelet dose by doubling the PRP injection volume, we are unaware of any studies looking at controlling injection dosing across different PRP volumes and the ensuing impacts on clinical outcomes. For example, injecting 4mL of 10 billion platelets in Kellgren-Lawrence (KL) 2 knee OA patients vs injecting 8mL of 10 billion platelets in Kellgren-Lawrence (KL) 2 knee OA patients. 

As noted by Dr. Don Buford in his editorial piece published in August 2024 in the Journal Orthopaedic Experience & Innovation found, there are fifteen factors providers can use to better assess the literature, plan future investigations, and select the correct PRP therapy. [2]

1. PRP volume (cc)

2. WBC count

3. RBC count

4. Hemoglobin

5. Hematocrit

6. Platelet count

7. Lymphocyte % and #

8. Monocyte % and #

9. Neutrophil/Granulocyte % and #

10. Platelet concentration factor (over baseline platelet count)

11. Platelet recovery %

12. PRP volume output consistency (ie. the % of time a protocol makes the same PRP volume from the same whole blood input)

13. PRP protocol time (ie. centrifuge time to make PRP)

14. PRP kit cost ($)

15. PRP kit cost/billion platelets ($/billion platelets)

It’s important to note that PRP treatment approaches should be tailored to each specific condition and patient, considering factors such as platelet dose, injection volume, and frequency of treatment, not to mention the leucocyte and red blood cell profile of the injectate. As research in this field continues to evolve, treatment protocols may be further refined for each specific condition.

Healthcare providers should consider the current evidence, individual patient factors, specific condition characteristics, and anatomical considerations when determining the most appropriate PRP treatment approach, including both platelet dosage and volume. For some conditions, particularly those with limited research, treatment protocols may need to be adapted from similar conditions or based on expert consensus until more definitive studies are available. In addition, patient reported outcomes registries such as Data Biologics which have been designed to capture real-world outcome data along with our HORIBA cell counter data can also be consulted to better inform PRP dosing and volume decisions given the paucity of evidence across some MSK conditions.

PLYMOUTH MEDICAL is pleased to conclude that with the latest Meta-Anslysis for PRP dosing across several MSK conditions, the training we offer our clients on targeting the best PRP kits coupled with the formulation and injectate volume flexibility continue to exceed the needs of our most discerning clients and those of their patients who require high platelet dosing in flexible injectate volumes. We recommend 30cc kits for 5 billion platelet dosing needs, 60cc kits for 10 billion platelet dosing needs and 120cc kits for treating multiple indications in 1 clinic visit (>20 billion platelet dosing). 

Feel free to reach out to our team and enquire about our products and training.

CITATIONS

[1] Berrigan, W., Tao, F., Kopcow, J. et al. The Effect of Platelet Dose on Outcomes after Platelet Rich Plasma Injections for Musculoskeletal Conditions: A Systematic Review and Meta-Analysis. Curr Rev Musculoskeletal Med (2024). https://doi.org/10.1007/s12178-024-09922-x

[2] https://journaloei.scholasticahq.com/article/118697-in-my-experience-15-data-points-to-better-evaluate-platelet-rich-plasma-kits-and-protocols

11/30/2024