PRPCalc2: An App for Platelet-Rich Plasma Preparation.

Platelet-rich plasma (PRP), an inexpensive yet powerful treatment modality, is widely used but poorly understood. Three areas of unmet need are the ability to compare results using differing centrifuges and methods; translating a study result into a specific practice; and estimating yield and dosage without the benefit of an in-office hematology analyzer. PRPCalc2 is a set of software tools that facilitates these goals. The app consists of software tools that (1) calculate the appropriate radius for centrifugation, (2) calculate the correct revolutions per minute (RPM) for the centrifuge, (3) calculate the mean yield for the method and its confidence interval, and (4) calculate platelet dosage. Using these tools, a practitioner with any centrifuge can create and validate their own PRP preparation method and then use it to create a standardized PRP.

Dextrose Effects on Platelet Count and Volume: Implications for Regenerative Medicine.

Platelet-rich plasma (PRP) and hypertonic dextrose solutions are commonly used injectates in regenerative medicine, sometimes used simultaneously. The effects of hypertonic dextrose on platelet lysis and activation have not been previously reported. We tested the effects of escalating dextrose concentration on cell counts and cell volume of platelets and red cells in PRP and whole blood (WB). A prompt partial reduction in platelet count occurred with all dextrose admixtures with either PRP or whole blood, consistent with partial lysis. After the first minute, platelet counts remained stable, suggesting a rapid accommodation of residual platelets to extreme (>2000 mOsm) hypertonicity. A 25% or higher dextrose concentration caused a significant increase in mean platelet volume (MPV), which suggests an early phase of platelet activation. Further investigation is warranted to confirm if platelet lysis or activation has occurred and whether additive clinical benefit may result from hypertonic dextrose injection alone or in combination with PRP.

A Novel Somatic Treatment for Post-traumatic Stress Disorder: A Case Report of Hydrodissection of the Cervical Plexus Using 5% Dextrose.

Despite years of standard treatments, a Marine veteran and former firefighter, disabled due to severe post-traumatic stress disorder (PTSD), worsened over ten weeks while receiving usual care. Bilateral injection of 10 mL of 5% dextrose in water using a 30-gauge needle just under the sternocleidomastoid muscle was performed at weeks 10, 12, 14, 16, and 18. Clinically important improvements were observed by 18 weeks on a 0-10 anxiety rating scale (57%), the PTSD checklist for civilians (41%), EuroQol overall quality of life scale (40%), and the Hospital Anxiety and Depression Scale (28%). Improvements were stable through 22 weeks. He reported symptomatic benefit on anxiety within 20 minutes of injection, suggesting a neurogenic mechanism, potentially related to a therapeutic effect on the nearby sympathetic trunk/superior sympathetic ganglion. Advantages of this procedure over stellate ganglion blockade include its safety (no lidocaine), bilateral treatment option, simplicity, and comfort.

Self-Treatment of Chronic Low Back Pain Based on a Rapid and Objective Sacroiliac Asymmetry Test: A Pilot Study.

BACKGROUND: Low back pain (LBP) is common, costly, and disabling. This study assesses a novel and simple LBP evaluation method and its merit in guiding the direction of a self-treatment exercise. METHODS: Randomized open-label intention is used to treat the study. Consecutive patients with LBP ≥ three months and pain ≥ 5/10 were evaluated in a Vancouver clinic with the sacroiliac forward flexion test (SIFFT) by comparing the height of posterior superior iliac spines using a level. Those with asymmetry ≥ 5 mm were offered participation. The assistant, who generated and encrypted the randomization, assigned participants: group 1 learned a two-minute, SIFFT-derived, sacroiliac-leveling exercise (SIFFT-E) as needed for LBP relief; group 2 used a pelvic stabilization belt as needed to prevent LBP, and group 3 continued the usual care. After one month, all participants used SIFFT-E and belt as needed for one month. The identifier number of this article in Clinicaltrials.gov is #NCT03888235. The trial is closed. Our primary outcome measure was the Oswestry disability index (ODI) (decrease) from baseline to one and two months. We also followed SIFFT improvement (decrease). FINDINGS: Of 72 LBP patients, 62 (86%) had ≥ 5 mm asymmetry. From zero to one month, the 21 (one dropout) SIFFT-E participants outperformed the 20 usual care participants for ODI improvement (12.5 ± 14.8 vs. -3.4 ± 14.9 points; mean difference 15.9 [CI 6.7-25.0]; P = 0.002 with number needed to treat (NNT) of 3.0 for ODI improvement ≥ 11). Belt use results were intermediate. At two months, after all the 62 participants used the exercise and belt as needed, combined ODI improvements were clinically significant (12.0 ± 18.4 points), and SIFFT asymmetry was reduced by 8.6 ± 8.6 mm. Five (8%) exercise and 12 (19%) belt wearers experienced mild side effects. INTERPRETATION: Sacroiliac asymmetry appears to be frequent. SIFFT may be clinically useful as an evaluation tool for prescribing a simple self-directed corrective exercise as seen by clinically significant improvements in function and asymmetry.

Platelet-Rich Plasma Centrifugation Changes Leukocyte Ratios.

Platelet-rich plasma (PRP) is usually described with respect to its platelet concentration and sometimes the concentration of erythrocytes and leukocytes. In this study, we examined the numbers of leukocyte subtypes in PRPs prepared by five different methods. Single spin PRP methods evaluated resulted in a significant increase in the percentage of lymphocytes and proportional/inverse reduction of the percentage of granulocytes in comparison to those percentages found in whole blood. We propose that the centrifugation process traps the denser granulocytes in the RBC layer more readily than lymphocytes and that this will vary by g force and time. The PRP preparation method may be clinically relevant, because the distribution of leukocytes may affect clinical outcomes.

Ultrasound-Guided Nerve Hydrodissection for Pain Management: Rationale, Methods, Current Literature, and Theoretical Mechanisms.

Nerve hydrodissection (HD), a technique used when treating nerve entrapments, involves the injection of an anesthetic, saline, or 5% dextrose in water to separate the nerve from the surrounding tissue, fascia, or adjacent structures. Animal models suggest the potential for minimal compression to initiate and perpetuate neuropathic pain. Mechanical benefits of HD may relate to release of nervi nervorum or vasa nervorum compression. Pathologic nerves can be identified by examination or ultrasound visualization. The in-plane technique is the predominant and safest method for nerve HD. Five percent dextrose may be favored as the preferred injectate based on preliminary comparative-injectate literature, but additional research is critical. Literature-based hypotheses for a direct ameliorative effect of dextrose HD on neuropathic pain are presented.

Platelet yield and yield consistency for six single-spin methods of platelet rich plasma preparation.

Single-spin methods of preparation of platelet-rich plasma are used widely in private practice, yet they have not been extensively studied and compared. The use of platelet-rich plasma (PRP) by the private practitioner can be facilitated by efficient and predictable PRP preparation. The primary purpose of this study was to study common methods of single-spin PRP preparation to determine their efficiency and variability. Six single-spin methods of PRP production from whole blood were analyzed. The primary measures were mean yield and standard deviation as the quotient of total platelet count in PRP produced divided by total platelet count in whole blood utilized. Each sample was analyzed in triplicate and the results were averaged. Secondary measures included red blood cell count (RBC) and white blood cell count (WBC), concentration ratio, and variable cost per million platelets produced. Sixty-four volunteers provided samples from 30 June 2017 to 30 September 2018. Seventeen to twenty six samples were utilized to assess each method. Yields for the six preparation methods (PMs) varied from 53(±18)% to 72(±13)%. Differences were observed for WBC count (1.8 to 14), Hematocrit (0.8 to 32), platelet concentration (568 to 1062), and variable cost per billion platelets produced ($1.55 to $44.31). All six methods evaluated provided a platelet yield of more than 50%, although two methods were less efficient than the others. Two methods were able to produce leukocyte-poor PRP. Variability was moderate across all methods, suggesting that estimation of platelet yield should be feasible from a baseline platelet count for all methods.

Treatment of Temporomandibular Dysfunction With Hypertonic Dextrose Injection (Prolotherapy): A Randomized Controlled Trial With Long-term Partial Crossover.

OBJECTIVE: To assess the efficacy and longer-term effectiveness of dextrose prolotherapy injections in participants with temporomandibular dysfunction. PATIENTS AND METHODS: A randomized controlled trial with masked allocation was conducted from January 14, 2013, through December 19, 2015. Forty-two participants (with 54 joints) meeting temporomandibular dysfunction criteria were randomized (1:1) to 3 monthly intra-articular injections (20% dextrose/0.2% lidocaine or 0.2% lidocaine) followed by as-needed dextrose/0.2% lidocaine injections through 1 year. Primary and secondary outcome measures included a 0 to 10 Numerical Rating Scale score for facial pain and jaw dysfunction; maximal interincisal opening (MIO) measured in millimeters, percentage of joints with 50% or more change (improvement) in pain and function, and satisfaction. RESULTS: Randomization produced a control group with more female participants (P=.03), longer pain duration (P=.01), and less MIO (P=.01). Upon 3-month analysis, including pertinent covariates, dextrose group participants reported decreased jaw pain (4.3±2.9 points vs 1.8±2.7 points; P=.02), jaw dysfunction (3.5±2.8 points vs 1.0±2.1 points; P=.008), and improved MIO (1.5±4.1 mm vs -1.8±5.1 mm; P=.006). Control group participants received dextrose injections beginning at 3 months. No between-group differences were noted at 12 months; pooled data suggested that jaw pain, jaw function, and MIO improved by 5.2±2.7 points (68%), 4.1±2.8 points (64%), and 2.1±5.5 mm, respectively. Pain and dysfunction improved by at least 50% in 38 of 54 (70%) and 39 of 54 (72%) jaws, respectively. CONCLUSION: Intra-articular dextrose injection (prolotherapy) resulted in substantial improvement in jaw pain, function, and MIO compared with masked control injection at 3 months; clinical improvements endured to 12 months. Satisfaction was high. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01706172.

Topical Mannitol Reduces Capsaicin-Induced Pain: Results of a Pilot-Level, Double-Blind, Randomized Controlled Trial.

BACKGROUND: Capsaicin specifically activates, and then gradually exhausts, the transient receptor potential vanilloid type 1 (TRPV1) receptor, a key receptor in neuropathic pain. Activation of the TRPV-1 receptor is accompanied by burning pain. A natural substance or medication that can reduce the burning pain resulting from capsaicin application may have therapeutic potential in neuropathic pain. OBJECTIVE: To assess the pain-relieving effects of a mannitol-containing cream in a capsaicin-based pain model. DESIGN: Randomized, placebo-controlled, double-blind clinical trial. SETTING: Outpatient pain clinic. PARTICIPANTS: Twenty-five adults with pain-free lips. METHODS: Capsaicin .075% cream was applied to both halves of each participant's upper lip, inducing pain via stimulation of the transient receptor potential vanilloid 1 (TRPV1, capsaicin) receptor, then removed after 5 minutes or when participants reported a burning pain of 8/10, whichever came first. A cream containing mannitol and the same cream without mannitol (control) were then immediately applied, 1 on each side of the lip, in an allocation-masked manner. OUTCOME MEASURES: Participants self-recorded a numeric rating scale (NRS, 0-10) pain score for each side of the lip per minute for 10 minutes. A t-test was performed to evaluate the pain score change from baseline between each side of the lip at each recording. Area under the curve (AUC) analysis was used to determine the overall difference between groups. RESULTS: Participants reached a capsaicin-induced pain level of 7.8 ± 1.0 points in 3.3 ± 1.6 minutes that was equal on both sides of the lip. Both groups reported progressive diminution of pain over the 10-minute study period. However, participants reported significantly reduced pain scores on the mannitol cream half-lip compared to control at 3 through 10 minutes (P < .05) and in AUC analysis (P < .001). CONCLUSIONS: Mannitol cream reduced self-reported pain scores in a capsaicin pain model more rapidly than a control cream, potentially via a TRPV1 receptor effect.

Ultrasonography in regenerative injection (prolotherapy) using dextrose, platelet-rich plasma, and other injectants.

Recent advances in ultrasound technology are leading physiatrists to new understandings of pain sources, new treatment options, and the ability to guide soft tissue interventions. This article examines the role of imaging ultrasound in diagnosing soft tissue injury and disease that may respond to regenerative medicine techniques (known as prolotherapy) using injectants such as dextrose, morrhuate sodium, or platelet-rich plasma. The current state of ultrasound evidence for these interventions is reviewed. Case examples assist in understanding clinical applications that currently outpace the evidence base. Development of quantitative ultrasound measures to objectively evaluate soft tissue organization is discussed.

Aerosolized alpha-hemolytic Streptococcus as a cause of knee sepsis after intra-articular injection: predisposing factors.

Joint sepsis from an aerosol source of any organism during knee injection has never been reported and the standard of care for joint injection does not include facial masking. This case collection suggests that simple talking or teaching during injection procedures near an open hub needle may create a significant aerosol contamination risk with viridans group alpha-hemolytic strep. In addition, it suggests that the pathogenicity of alpha-hemolytic Streptococcus may be facilitated by the combination of dextrose and methylprednisolone. This finding has potential implications for the use of protective masking and/or avoidance of verbal communication (teaching or patient explanations) during the process of knee injection, especially of patients who are in an immunocompromised state. Potential parallels with the literature on aerosol-transmitted postdural meningitis with alpha hemolytic strep are explored.

Regenerative injection of elite athletes with career-altering chronic groin pain who fail conservative treatment: a consecutive case series.

OBJECTIVE: To obtain multisport and long-term outcome data from the use of regenerative injection therapy on career-threatened athletes. DESIGN: Consecutive enrollment of elite performance-limited athletes with chronic groin/abdominal pain who failed a conservative treatment trial. The treatment consisted of monthly injections of 12.5% dextrose in 0.5% lidocaine in abdominal and adductor attachments on the pubis. Injection of the nociceptive source was confirmed by repetition of resistive testing 5 mins after injection. RESULTS: Seventy-five athletes were enrolled. Seventy-two athletes (39 rugby, 29 soccer, and 4 other) completed the minimum two-treatment protocol. Their data revealed a mean groin pain history of 11 (3-60) mos. Average number of treatments received was 3 (1-6). Individual paired t tests for Visual Analog Scale (VAS) of pain with sport (VAS Pain) and Nirschl pain phase scale measured at 0 and an average of 26 (6-73) mos indicated VAS Pain improvement of 82% (P < 10) and Nirschl pain phase scale improvement of 78% (P < 10). Six athletes did not improve following regenerative injection therapy treatment, and the remaining 66 returned to unrestricted sport. Return to unrestricted sport occurred in an average of 3 (1-5) mos. CONCLUSIONS: Athletes returned to full elite-level performance in a timely and sustainable manner after regenerative injection therapy using dextrose.

Treatment of painful advanced internal lumbar disc derangement with intradiscal injection of hypertonic dextrose.

BACKGROUND: Degenerative discs are thought to produce nerve root pain either mechanically or chemically. Particularly in the case of advanced degenerative disc disease, this clinical entity has often proven to be symptomatically resistant to peridural steroids, Intra-discal Electrothermoplasty (IDET) and direct surgical intervention. Exposure of irritated nerves to hypertonic dextrose is thought to have chemoneuromodulatory potential. Sustained pain reduction has been demonstrated in a pilot study involving injection of a combination of dextrose, glucosamine, chondroitin and dimethylsulfoxide into degenerative discs of patients with chronic low back pain of discogenic origin. OBJECTIVE: To assess the effects of disc space injections of hypertonic dextrose in patients experiencing chronic advanced degenerative discogenic leg pain, with or without low back pain. STUDY DESIGN: Prospective consecutive patient series. METHODS: Patients with moderate to severe degenerative disc disease without herniation and with concordant pain reproduction with CT discography were included. All had failure of a physical therapy trial and substantial but temporary relief with two fluoroscopically guided epidural steroid injections. Patients underwent bi-weekly disc space injection of a solution consisting of 50% dextrose and 0.25% Bupivacaine in the disc(s) found positive on discography. The study was performed in an out-patient surgery center in the United States. Outcome measures included an 11-scale numeric pain score (0-10). RESULTS: Each patient was injected an average of 3.5 times. Overall, 43.4% of patients fell into the sustained improvement group with an average improvement in numeric pain scores of 71%, comparing pretreatment and 18 month measurements. CONCLUSION: The results suggest that intradiscal injection of hypertonic dextrose may have a place in the management of pain arising from advanced lumbar degenerative disc disease.

Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain.

OBJECTIVE: To determine the efficacy of simple dextrose prolotherapy in elite kicking-sport athletes with chronic groin pain from osteitis pubis and/or adductor tendinopathy. DESIGN: Consecutive case series. SETTING: Orthopedic and trauma institute in Argentina. PARTICIPANTS: Twenty-two rugby and 2 soccer players with chronic groin pain that prevented full sports participation and who were nonresponsive both to therapy and to a graded reintroduction into sports activity. INTERVENTION: Monthly injection of 12.5% dextrose and 0.5% lidocaine into the thigh adductor origins, suprapubic abdominal insertions, and symphysis pubis, depending on palpation tenderness. Injections were given until complete resolution of pain or lack of improvement for 2 consecutive treatments. MAIN OUTCOME MEASURES: Visual analog scale (VAS) for pain with sports and the Nirschl Pain Phase Scale (NPPS), a measure of functional impairment from pain. RESULTS: The final data collection point was 6 to 32 months after treatment (mean, 17 mo). A mean of 2.8 treatments were given. The mean reduction in pain during sports, as measured by the VAS, improved from 6.3+/-1.4 to 1.0+/-2.4 ( P <.001), and the mean reduction in NPPS score improved from 5.3+/-0.7 to 0.8+/-1.9 ( P <.001). Twenty of 24 patients had no pain and 22 of 24 were unrestricted with sports at final data collection. CONCLUSIONS: Dextrose prolotherapy showed marked efficacy for chronic groin pain in this group of elite rugby and soccer athletes.

Long-term effects of dextrose prolotherapy for anterior cruciate ligament laxity.

CONTEXT: Use of dextrose prolotherapy. Prolotherapy is defined as injection that causes growth of normal cells or tissue. OBJECTIVE: Determine the 1 and 3 year efficacy of dextrose injection prolotherapy on anterior cruciate ligament (ACL) laxity. After year 1, determine patient tolerance of a stronger dextrose concentration (25% versus 10%). DESIGN: Prospective consecutive patient trial. SETTING: Outpatient physical medicine clinic. PATIENTS OR OTHER PARTICIPANTS: Eighteen patients with 6 months or more of knee pain plus ACL knee laxity. This laxity was defined by a KT1000 anterior displacement difference (ADD) of 2 mm or more. INTERVENTION: Intraarticular injection of 6-9 cc of 10% dextrose at months 0, 2, 4, 6, and 10. Injection with 6 cc of 25% dextrose at 12 months. Then, depending on patient preference, injection of either 10% or 25% dextrose every 2-4 months (based on patient preference) through 36 months. MAIN OUTCOME MEASURES: Visual analogue scale (VAS) for pain at rest, pain on level surfaces, pain on stairs, and swelling. Goniometric flexion range of motion, and KT1000-measured ADD were also measured. All measurements were obtained at 0, 6, 12 and 36 months. RESULTS: Two patients did not reach 6 month data collection, 1 of whom was diagnosed with disseminated cancer. The second was wheelchair-bound and found long-distance travel to the clinic problematic. Sixteen subjects were available for data analysis. KT1000 ADD, measurement indicated that 6 knees measured as normal (not loose) after 6 months, 9 measured as normal after 1 year (6 injections), and 10 measured as normal at 3 years. At the 3 year follow-up, pain at rest, pain with walking, and pain with stair use had improved by 45%, 43%, and 35% respectively. Individual paired t tests indicated subjective swelling improved 63% (P = .017), flexion range of motion improved by 10.5 degrees (P = .002), and KT1000 ADD improved by 71% (P = .002). Eleven out of 16 patients preferred 10% dextrose injection. CONCLUSION: In patients with symptomatic anterior cruciate ligament laxity, intermittent dextrose injection resulted in clinically and statistically significant improvement in ACL laxity, pain, swelling, and knee range of motion.