Chiropractor Chandler AZ

Platelet-Rich Prolotherapy for Neck pain

PLATELET-RICH PLASMA PROLOTHERAPY

Platelet-Rich Plasma Prolotherapy is a non-surgical, injection-based procedure which is used to treat conditions like musculoskeletal pains and sports related injuries. A U.S.-based physician, George Hackett, designed the protocol for the Prolotherapy technique in the 1950s. Platelet-Rich Plasma Prolotherapy is the modern version of Prolotherapy.

Previously, platelets were thought to have a role in blood clotting only, but with the recent research, a new role of platelets in wound healing and tissue regeneration has been discovered. This ability of platelets is used in Platelet-Rich Plasma Prolotherapy. The Platelet-Rich Plasma is the autologous blood which contains a higher concentration of platelets (93%).

In this technique, platelet-rich plasma is injected at the location of pain where it releases growth factors which are proteins that stimulate tissue regeneration and healing. Activated platelets also signal the repair cells including the adult stem cells to come to the injury cells thus repairing the damaged cells.

USES OF PLATELET-RICH PLASMA PROLOTHERAPY

The effectiveness of PRP therapy varies depending on the following:

1. Area of the body being treated
2. The overall health of the person being treated
3. The severity of the injury

PRP therapy is used to treat a wide variety of medical conditions such as:

1. Chronic tendon injuries especially tennis elbow. PRP therapy is the most effective technique for the treatment of tennis elbow.
2. Acute ligament and muscle injuries such as acute sports injuries.
3. After shoulder surgery to repair torn rotator cuff tendons, PRP therapy is used to enhance the healing process.
4. Knee arthritis
5. Fractures
6. Musculoskeletal pain

PREPARATION FOR PLATELET-RICH PLASMA PROLOTHERAPY

The source of Platelet-Rich Plasma is the blood of the patient. 30 cc's of blood is drawn at the time of treatment which will give 3-5 cc's of platelet-rich plasma. The amount of platelet-rich plasma depends on the baseline platelet count of the patient. Anticoagulants are used to prevent platelet activation before its use. The process used to prepare platelet-rich plasma is called differential centrifugation.

In this method, a centrifuge machine is used to separate different components of the blood based on their specific gravity.

This process is divided into two steps. In the first spin, the red blood cells are separated from the white blood cells and platelets. After the first spin, the white blood cells are divided into three layers: the upper layer contains platelets and white blood cells, intermediate layer contains white blood cells, and the bottom layer contains red blood cells. The upper layer is separated into another container and the second spin is performed to get Platelet-rich plasma.

There are three factors that affect the Platelet-rich plasma concentration:

1. Centrifugal force
2. Temperature
3. Time
4. Anticoagulants
5. Amount of blood drawn

TREATMENT PROCEDURE

The area of the injury is marked by using data from MRI or radiographs. For an effective localized injection, an ultrasound is used to monitor the location of the injection. A local anaesthesia is applied at the site of injection and then the platelet-rich plasma injection is applied with ultrasound guidance. The procedure is repeated based on the severity of the injury. The patient can feel soreness or pain at the site of injection which can last up to a week.

BENEFITS OF PLATELET-RICH PLASMA PROLOTHERAPY

Since the blood used in platelet-rich plasma Prolotherapy is drawn from the same individual under treatment, there are no chances of an immune reaction. Also, the chances of blood borne infection transfer are eliminated.

SAFETY ISSUES AND ADVERSE EFFECTS INVOLVED IN PLATELET-RICH PLASMA PROLOTHERAPY

Platelet-rich plasma prolotherapy has low risks and side effects. Major risk involved in platelet-rich plasma prolotherapy is hyperplasia, that is, an increase in tissue size due to excessive cell growth. However, studies have found no evidence of hyperplasia, cancer, or tumour growth. The adverse effects of platelet-rich plasma Prolotherapy can be:

1. Infection
2. No relief of symptoms
3. Neurovascular injury
4. Scar tissue formation
5. Allergic reaction

Another side effect is that it is not a quick fix and can take up to 4-6 months to treat the pain completely.

PLATELET-RICH PLASMA PROLOTHERAPY FOR NECK PAIN

A study conducted at Stanford University in 2006 to evaluate the successful use of platelet-rich plasma therapy for chronic elbow tendinosis showed a 93% reduction in pain 2 years after the treatment. Although there are differences in the administration methods and uncertainty of the healing mechanism of platelet-rich plasma prolotherapy, the early evidence of its use for musculoskeletal induced pains are encouraging. In vitro and animal studies have shown positive results of PRP prolotherapy in different tissue injuries including muscles, tendons, meniscus, ligaments, cartilage, nerve, and intervertebral disc.

The neck is one of the most important parts of our body as one of its functions is to control head movement. The spinal column and spinal cord starts from the neck and extends to the pelvis. The portion of the spine in the neck is called the cervical spine. The cervical spine is prone to injury since it is used extensively. Any injury or stress to the cervical spine can lead to severe neck pain which can spread to the head, shoulders, arms, and hands.

Neck pain is becoming extremely common especially with advancement in technology and industrialization. It affects 30-50% of the overall population annually. Almost 11-14% of the working population experiences severe pain that can lead to restricted mobility of the neck. The chances of having neck pain increases with age. Neck pain is more prevalent in women as compared to men.

Neck pain can be divided into two types based on the amount of injury and duration of pain: acute or chronic. Acute pain arises suddenly and it heals quickly. It is usually caused by damage to a muscle, ligament, joint, or disc. Chronic neck pain lasts for more than three months. Factors causing chronic neck pain are nerve damage, tissue scarring, or arthritis.

The signs and symptoms of neck pain can lead from stiffness, pain in the neck, sore muscles to muscle spasms and restricted neck movement. In severe cases, the patient cannot even move his head. In the case of nerve damage, pain, weakness, and numbness can spread to the shoulders, arms, and hands as well. In the case of brain infection or bleeding, the patient can develop fever, nausea, severe headache along with neck pain.

A complete medical exam is required to identify the cause of neck pain and the most suitable treatment options to relieve the pain. The goal of treatment is to restore the movement of the neck, relieve pain, and prevent any further damage.

Simple home treatments are recommended for patients with severe neck pain to restore movement of the neck joints and muscles. Self-care such as rest, massage, and gentle stretches helps in reducing neck pain.

Surgery is rarely needed when the pain does not go away after long non-surgical treatments.

Initial Medical Treatments

NSAIDs are often prescribed for the initial acute injury stages. In severe cases that involve multiple joint regions, muscle relaxers or oral steroids can be given. Trigger point injections, botox, or steroid injections can be treatment options. Pain management is not usually required unless stronger medications or joint injections are required for treatment.

MRI and X-rays will not usually be ordered to evaluate mild to moderate muscle, tendon, and ligament injuries. Severe cases may utilize advanced imaging to rule out bone fractures, edema, nerve entrapments, tendon or muscle ruptures. NCV testing may be utilized in cases that also involve muscle, sensory, or reflex loss which indicates nerve damage.

Cervical spinal disc bulges and herniations onto the spinal cord or nerve root produce different symptoms and location of symptoms. Pain radiating in the hand is one symptom; along with numbness, weakness, fatigue, loss of sensation, or reduced reflexes. Your chiropractor, physical therapist, occupational therapist, or physician will evaluate your condition and make a proper diagnosis and treatment recommendations. Ask them any questions you might have about your injury.

Not all injuries respond to initial treatments, especially if the condition is chronic and degenerative changes are found inside the joint surfaces. Some arthritic changes will respond very well to platelet rich plasma or stem cell therapies.

Platelet Rich Plasma Therapy For Neck Pain

A modern approach towards treating musculoskeletal injuries and pain is Platelet-rich plasma prolotherapy. Platelet-rich plasma therapy is the most effective therapy for treating ligament injuries. In this treatment, the platelet-rich plasma is injected into the site of pain. Platelets release growth factors that attract repair cells and speed up the healing process. The duration of platelet-rich plasma therapy for a whiplash injury is usually one hour. The patient can go home on the same day. The recovery time from the injection is one week. To treat the whiplash, platelet-rich plasma therapy is required 3-4 times. When the neck joints and ligaments are repaired, the muscles will relax and the pain will improve.

Further studies are required to evaluate the long-term side effects of the PRP Prolotherapy technique, the effect of PRP storage on its efficacy, and to develop a standardized protocol for the PRP Prolotherapy technique.

Conservative Therapy Combined With PRP

After receiving a PRP injection, conservative therapy can greatly enhance the healing process and eliminate muscle spasms and soft tissue injuries contributing to your neck pain. Several types of treatment are commonly recommended, especially for people who slouch and have a forward leaning posture.

Slouching and Its Effect on the Neck and Back

Slouching, quite basically, is sitting or standing with your head and shoulders drooping forward. When you slouch, not only does your neck stick out forward, but your shoulder blades destabilize, and your middle back curves in the wrong direction.

Prolonged slouching has been found to be the most common cause of neck and back pain. When you have good posture, the weight of your head is directly above your shoulders. But every inch your head moves forward increases the strain on your muscles and tendons. Thus, poor posture can often lead to tension headaches, migraine headaches, tendonitis, shoulder pain, jaw pain, and disc injuries.

How Do You Get Neck Pain and Back Pain from Slouching?

When your neck protrudes forward, your head does likewise, away from your center of gravity. This causes the entire weight of the head to be placed on the wrong areas. Sitting like this for long periods of time overwhelms these joints and muscles, leading to injury and pain.

Over time, the shoulder blades that anchor the neck destabilize, stretching and tightening the wrong back muscles, and causing the middle back to curve outward. In turn, this forward stretch causes the back muscles, or back extensors, to weaken.

Thus, prolonged slouching weakens and damages your muscles and joints, leading to chronic neck and back pain. Increasing joint and muscle strain also often increases the chances of developing further neck pain from sleeping wrong, or from conducting normal exercises and movements.

Prevention of Neck and Back Pain from Slouching

Whether you are a habitual sloucher or your posture has recently started deteriorating, relief can be obtained by:

• Correcting your posture
• Relaxing your shoulders and back muscles
• Strengthening your back and scapular muscles
• Aligning your spine with chiropractic and physical therapy treatments

Conservative Treatments

Therapeutic treatments for addressing soft tissue injuries involve massage therapy, manual therapy, trigger point therapy, Graston Technique, or Active Release Technique. These treatments increase blood flow, decrease muscle spasms, enhance flexibility, speed healing, and promote proper tissue repair.

When these treatments are incorporated into a treatment plan patients heal faster and are less likely to have long-term pain or soft tissue fibrosis or scar tissue in the injured muscle. These soft tissue treatments are incorporated with therapeutic exercise and flexibility programs.

Treatment for headache symptoms may involve many prescription, over the counter, herbal, and homeopathic remedies. The neck muscles need to function appropriately and not remain in spasms, which alters neck spinal movements and postures. For those with arthritic degeneration in the cervical spine, restoring proper muscle function is even more important. This often requires people to change their postures, habits, and activities. Acupuncture has been known to help headache sufferers.

Working any muscles in the front of the neck is not comfortable, but it needs to be done to restore proper cervical and shoulder function. The neck, shoulder, scapula, and arm work as a functional unit to turn your head, raise your shoulder, or reach in front of you. Dysfunction in any of these muscles leads to pain and tendinopathy.

Chiropractic Adjustive Techniques

Chiropractic adjustments attempt to increase the movement of the joint complex. With injury, poor posture, sprains, and strains, muscles tighten up and the joints can become locked up. This lack of movement is felt when you look over your shoulder and feel a pulling, dull pain, or a twinge of pain. Mildly stuck joints can be loosened up in the day with stretching and range of motion exercises. Moderately stuck joints often need a little help to restore their normal motion with chiropractic adjustments. Severely stuck joints cause sharp and severe pain whenever they put pressure upon the joint or try and move the joint complex.

Joint complex injuries are common whenever a patient says they have pain when sitting or standing too long, or the pain always "starts right here." Pressing on an injured joint causes pain, and people noticed reduced range of motion looking over their shoulder.

Healthy joints do not experience pain with orthopedic testing. A healthy joint comfortably moves when light pressure is applied to the spinous process, rocking the joint back-and-forth. A mildly stuck joint feels a little stiff and a little sore to the patient. Whereas moderate and severe joint sprains cause immediate pain when pressure is applied.

There are multiple ways to get a joint moving again. The most important part is that the joint is moving in its proper range of motion and without pain. Many people think chiropractors only perform manual manipulation. Most likely their first experience with a chiropractic was years ago, and manual manipulation was the most common form of treatment. Over time and with technology, treatments have changed with the same goal of getting neck joints moving.

There are several very gentle ways to adjust an injured neck joint, including Activator Technique and Thompson Drop Technique. Activator utilizes a spring load instrument "bump" the joint and increase joint motion before the muscles tighten up. Thompson Drop Technique utilizes specific tables that drop two inches to increase the motion without turning or rotating the neck. Learn more about types of chiropractic adjustments.

Low Level Laser Treatments

1. ACCELERATED TISSUE REPAIR AND CELL GROWTH

Photons of light from lasers penetrate into tissue and accelerate cellular growth and reproduction. Laser therapy increases the energy available to the cell so it can work faster, better, and quickly get rid of waste products. When cells of tendons, ligaments, and muscles are exposed to laser light they repair and heal faster.

2. FASTER WOUND HEALING

Laser light increases collagen production by stimulating fibroblasts. Collagen is the building block of tissue repair and healing. Laser therapy increases fibroblast activity and therefore collagen production to speed healing.

3. REDUCED FIBROUS TISSUE FORMATION

Low level laser therapy decreases scar tissue formation. Scar tissue can be a source of chronic pain and poor healing. By eliminating excessive scar tissue and encouraging proper collagen production, painful scars and chronic pain is reduced.


4. ANTI-INFLAMMATION

Laser therapy causes vasodilatation (increases size of capillaries) which increases blood flow. The treatments also increases lymphatic drainage to decrease swelling or edema. Therefore, laser therapy reduces swelling caused by bruising or inflammation while speeding the recovery process.

5. PAIN RELIEF

Cold laser therapy decreases pain by blocking pain signals to the brain. Some nerve cells sense pain and send signals to the brain. Chronic pain can be caused by overly active pain nerves. Specific wavelengths help "shut off" the pain signals, thereby; eliminating your pain.

Low level lasers are excellent at decreasing inflammation, which also increases pain nerve activity. Cold laser therapy also increases endorphins and enkephalins, which block pain signals and decrease pain sensation. Overall laser therapy reduces painful nerve signals and reducing your perceived pain.

6. INCREASED BLOOD FLOW

Blood carries nutrients and building blocks to the tissue, and carries waste products away. Increased blood flow to tissues increases and enhances cellular healing. Cold laser therapy increases the formation of capillaries in damaged tissue. Specific laser frequency also increases blood flow to the area treated, to enhance injury repair.

7. INCREASED REPAIR AND REGENERATION

Low level lasers increases enzyme activity to improve metabolic activity that affects cell repair and regeneration. The enzymes are turned on "high" to speed the healing.

8. NERVE FUNCTION AND REPAIR

Nerves heal very slowly. Lasers speed up this process. Damage to nerves causes numbness, pain, muscle weakness, and altered sensations. Laser therapy treatments enhance nerve function, healing, and reduce pain.

9. INCREASED ENERGY PRODUCTION - ATP

ATP is like gasoline for cells, it is the energy source that cells operate. Injured cells often have low levels of ATP, which decreases their ability to heal and repair. By increasing ATP and "gasoline storage levels," cells have more ATP for healing and repair. Increased mitochondrial production is very important with nerve pain.

10. ACUPRESSURE AND TRIGGER POINTS

Graston Technique For Soft Tissue Pain and Scar Tissue

Graston Technique is utilized in many professional, Olympic, and collegiate sports therapy programs. Specifically-designed stainless steel instruments have rounded, concave and convex edges. The edges are not sharp. Graston tools are classified under Instrument Assisted Soft Tissue Mobilization (IASTM) and are used to detect and effectively treat soft tissue fibrosis or chronic inflammation. With these instruments the practitioner can scan over and detect areas of fibrotic tissue.

There are six different Graston tools to help break up fascial restrictions or scar tissue that develops after trauma to muscles, ligaments, tendons, or fascia, which is commonly referred to as soft tissue. Scar tissue forms when tissue does not heal correctly, or is under chronic, repetitive stress. Scar tissue is weaker than normal muscle and connective tissue, which is why it becomes chronically sore with activity.

What is Scar Tissue and Fascial Adhesion?

Scar tissue accumulates in the body whenever tissue undergoes excessive stress and strain. Scar tissue is like the body's duct tape; it is meant as a short term patch to help support tissue. However, in some cases the scar tissue is not replaced with normal collagen fibers. Scar tissue is also referred to as fascial adhesions, as it causes restrictions between the body's fascia. Stiffness, loss of normal range of motion and chronic pain develops from patches of fascial adhesions.

The next time a scar tissue patch undergoes stress and strain it becomes aggravated and flares up. This process causes more scar tissue to be added to the outside of the patch and the process repeats itself over and over, leading to larger accumulation of scar tissue patches.

I like to describe scar tissue patches as "onions." Scar tissue ends up growing in layers around the initial injury. Stress to the area aggravates the outside layers and triggers another layer to be formed. The layers further from the center are easier to aggravate than the inside layers, which is why the onion continues to grow in size without causing the inside area to properly repair.

How Graston Technique Improves Treatment

Adding Graston Technique to any treatment decreases overall treatment time. It reduces the need for anti-inflammatory medication and enhances rehabilitation. Many patients with chronic conditions show significant improvement with IASTM. Your provider is trained in how to properly utilize the instrument assisted soft tissue mobilization of either Graston, Gua Sha, and ASTYM. Basic concepts and treatments with IASTM:

• Reduce the stress and strain to the injured areas.
• Decrease inflammation.
• Increase muscle flexibility and strength.
• Increase blood flow.
• Break up scar tissue.
• Promote proper tissue repair.
• Enhance functional movements.
• Accelerate fibroblast activity.

Home therapies are recommended to limit further scar tissue formation, encourage proper healing and speed up recovery. Braces and supports may be recommended for specific injuries.

Pulling Fascia Apart to Break Up Scar Tissue

Graston Technique works by stretching the outer layer of the "onion" and breaking it into several pieces. The Graston instruments use shear force to pull the top fascial layer across the bottom fascial layer. This pulling motion breaks up the scar tissue between the layers. The broken scar tissue triggers healing mechanisms to migrate into the tissue and properly repair the muscles and soft tissues.

Ice therapy helps limit additional scar tissue formation, inflammation, and pain. The next office visits breaks up the next layer of scar tissue, working toward the center of the onion. The goal is to get to the center of the onion so the body can fix the original problem.

Many sports therapy chiropractors, physical therapists, doctors, and athletic trainers have been properly trained in how to utilize the Graston tools.

Expectations of Therapy

Graston Technique is not meant to be painful and should be performed at a comfortably tolerable level to break up scar tissue. Being too aggressive with Graston Technique, Active Release Technique, manual therapy, cross friction therapy, or massage therapy causes excessive pain and actually slows the repair process by flooding the area with inflammation.

Treatment usually lasts a few minutes per area or region. As the treatment tool slides across the soft tissue fibrotic areas, the injury may feel bumpy or sandpaper-like. Redness and mild swelling may develop with treatment, especially after the first few treatments. In some cases, small petechiae or bruises may develop post-treatment. Ice therapy is commonly utilized post-treatment to limit the bruising, pain, and inflammation.

Most people notice a significant difference after 4-6 visits. Severe cases may take a little longer to see significant improvement. Runners, triathletes, and weekend warrior athletes have all benefited from this therapy. Over the course of treatment, most patients notice that less bumpiness, sandpaper, and tenderness is felt around the injury. As the treatment progresses, your healthcare provider will be able to apply more pressure, thereby treating deeper and deeper tissue levels.

Conservative Treatments Combined with Graston Technique

Therapeutic treatments for addressing soft tissue injuries involve massage therapy, manual therapy, trigger point therapy, or Active Release Technique combined with Graston Technique. These treatments increase blood flow, decrease muscle spasms, enhance flexibility, speed healing, and promote proper tissue repair.

When these treatments are incorporated into a treatment plan patients heal faster and are less likely to have long-term pain or soft tissue fibrosis or scar tissue in the injured muscle. These soft tissue treatments are integrated with therapeutic exercise and flexibility programs.

Soft tissue treatments restore proper muscle function and flexibility; and exercise restore strength, endurance, and neuromuscular control. Neuromuscular control is especially important and often not emphasised in many therapy clinics.

For any joint to work optimally the muscles need to contract and the exact right time. In many chronic injuries the muscles are not "firing" correctly leading to excessive strain on neighboring muscles and tendons. Many chronic rotator cuff injuries are the result of poor neuromuscular control.

Treatment for shoulder injuries combined with neck injuries often requires a variety of specific exercises, stretches, conservative treatments, medical treatments, and home therapies. Shoulder injuries can become chronic if all the muscles, tendons, and ligaments are not properly treated. Think of all the people who complain of their chronic rotator cuff or supraspinatus. The large neck muscles attach to the scapula, and muscle spasms alter scapular gliding movements. Eventually this poor movement patterns overwhelm the muscles and tendons of the shoulder leading to injuries.

When Do You Need Advanced Imaging?

MRI and X-rays will not usually be ordered to evaluate mild to moderate muscle, tendon, and ligament injuries. Severe cases may utilize advanced imaging to rule out bone fractures, edema, nerve entrapments, tendon or muscle ruptures. NCV testing may be utilized in cases that also involve muscle, sensory, or reflex loss.

Cervical spinal disc bulges and herniations onto the spinal cord or nerve root produce different symptoms and location of symptoms. Pain radiating in the hand is one symptom; along with numbness, weakness, fatigue, loss of sensation, or reduced reflexes. Your chiropractor, physical therapist, occupational therapist, or physician will evaluate your condition and make a proper diagnosis and treatment recommendations. Ask them any questions you might have about your injury.

Many people do have arthritis or degenerative changes in their neck and upper back spinal joints. Arthritis does not mean you will always have pain in the joints. Degenerative arthritis means the structural integrity of the bones have changed which alters its gliding, sliding, and hinging motions. The more severe the arthritic changes the easier it becomes to aggravate the joint and produce pain. Likewise joints may take longer to heal when joints have degeneration.

Osteoarthritis and rheumatoid arthritis will also slow healing and recovery time. However, arthritis does not mean a joint will always be painful. People with severe arthritis can eventually be pain free. In fact many times incorrectly blame their arthritis as the source of their pain when it is actually coming from injured tendons.

This is especially common in knee pain, where people believe their daily dull and sharp pain is osteoarthritis or meniscus tears when much of the pain is coming from chronic knee tendonitis in the small tendons that insert around the knee joint and patella bone. Graston Technique and a combination of conservative therapy treatments are especially effective at stimulating and enhancing tendon repair and eliminating chronic tendon pain.

In Conclusion

The neck and upper extremity work as a comprehensive unit performing many of the repetitive tasks at home, work, and recreational sports. Injuries to one area of the musculature often indicate that additional damage has been incurred by other muscles.

Many therapeutic exercises can help restore proper strength and endurance to the neck, shoulder, upper back and scapular muscles. Isometric exercises are often the initial neck treatment exercises. Followed by single plane rubber band exercises for flexion, extension, lateral flexion, and rotational movements. Dynamic exercises involving stability ball push-ups can be performed on the wall or floor. The more unstable of the surface the more effort and stabilization is required of all the upper back, scapular and shoulder muscles.

Push-ups on a stability ball enhances neuromuscular learning throughout the neck, scapula, shoulder, upper arm, and lower arm muscles. Additional strength exercises can be found on the arm and shoulder strengthening pages.

Our Chandler Chiropractic and Physical Therapy Clinic treats patients with a variety of muscle, tendon, joint, and ligament injuries. The clinic provides combination treatments for patients with neck and upper back pain. We frequently work with pain management and orthopedic surgeons for patients with complicated cases or after receiving injection therapy for pain and enhancing joint healing. We work with all ages and abilities of the residents in Phoenix, Tempe, Gilbert, Mesa, and Chandler AZ.

REFERENCES:

DeChellis, D. M., & Cortazzo, M. H. (2011). Regenerative medicine in the Field of Pain Medicine: Prolotherapy, Platelet-rich Plasma Therapy, and Stem Cell Therapy-Theory adn evidence. Techniques in Regional Anesthesia and Pain Management, 74-80. http://www.prolotherapy.com/DeChellis.pdf

Mishra, A., Harmon, k., Woodall, J., & Vieira, A. (2012 ). Sports Medicine Applications Of Platelet Rich Plasma. Curr Pharm Biotechnol, 1185-95. https://www.ncbi.nlm.nih.gov/pubmed/21740373

Rabago, D., Slattengren, A., & Zgierska, A. (2010). Prolotherapy in Primary Care Practice. Prim Care, 65-80. https://www.ncbi.nlm.nih.gov/pubmed/20188998

Sampson, S. (2008). Platelet Rich Plasma Injection Grafts For Musculoskeletal Injuries: A Review. Current Reviews in Musculoskeletal Medicine, 165-174. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2682411/

Sukesh, M., & Dhurat, R. (2014). Principles and Methods of Preparation of Platelet-Rich Plasma: A Review and Author's Perspective. J Cutan Aesthet Surg, 189-197. https://www.ncbi.nlm.nih.gov/pubmed/25722595