Precision PRP Therapy: What You Should Know About Photobiomodulation

Discover how precision PRP therapy for photobiomodulation can revolutionize treatment methods for better patient care.

Abstract

In this educational post, I will guide you through the latest evidence-based findings in orthobiologic therapies, focusing on the nuanced preparation and application of Platelet-Rich Plasma (PRP) and Protein Concentrate (PC). As Dr. Jimenez, with extensive credentials in integrated and functional medicine, my goal is to distill complex scientific principles into practical, understandable knowledge for clinicians and patients alike. We will explore the critical importance of achieving a high platelet recovery and dose, moving beyond simple concentration metrics to a more precise, therapeutic approach. I will detail the advanced techniques we use in my clinic to create a potent protein concentrate from platelet-poor plasma (PPP)—a component often discarded—and explain its significant role in combating the inflammatory processes of conditions like osteoarthritis. This includes an in-depth look at key proteins like Alpha-2-Macroglobulin (A2M) and Interleukin-1 Receptor Antagonist (IL-1ra).

Furthermore, I will share my comprehensive pre-procedure patient-optimization protocols, detailed ultrasound-guided shoulder injection techniques, and evidence-based post-procedure care strategies, including photobiomodulation. Finally, we will address common clinical questions, such as how to manage patients post-meniscectomy and how to clarify misconceptions about orthobiologic safety. This post aims to provide a thorough understanding of how these advanced regenerative strategies, integrated with chiropractic and functional medicine principles, offer a powerful pathway to healing and improved patient outcomes.

Understanding High-Quality PRP: Beyond Concentration to Absolute Dose

As a clinician dedicated to providing the most effective regenerative treatments, I emphasize the importance of understanding the quality and composition of the orthobiologics we use. It’s not just about using PRP; it’s about using the right PRP, tailored to each patient’s specific needs and condition.

A critical metric for me is elevated platelet recovery. In our practice, we aim for and consistently achieve an average platelet recovery of about 83%. This is crucial because some platelets inevitably remain in the plasma and the red blood cell (RBC) stack after centrifugation. Maximizing recovery ensures we are harvesting the greatest therapeutic potential from the patient’s own blood.

The versatility of our system is another cornerstone of my approach. It allows me to precisely dial in not just the volume of the injectate but also the specific components by selectively drawing from the buffy coat and the surrounding plasma. This control provides flexibility in creating the ideal injectate for a given joint or tissue, ensuring both simplicity and reproducibility. The output from a single 60 cc blood draw in our system averages an impressive 10.8 billion platelet dose. For those accustomed to the older “X-fold” terminology, this is roughly a 10-fold increase in concentration from the patient’s baseline platelet count.

A Deeper Dive: Analyzing the Injectate

Let’s look at a real-world example from my clinic to illustrate these points.

A patient’s whole-blood analysis showed a platelet count of 265,000 per microliter. In a 60 cc blood draw, this yields a total available platelet pool of 15.9 billion. After a single 10-minute centrifugation, we prepared a 7 cc PRP injectate. When we analyzed this final product, the platelet measurement was 2,128,000 per microliter.

Here’s the simple but powerful math:

• 2,128,000 platelets/µL x 7,000 µL (7 ccs) = 14.89 billion platelets.

This means we achieved a 94% platelet recovery rate for this specific sample, delivering a highly potent dose directly to the target tissue.

Equally important is what we reduce. Notice the following in our prepared sample:

• Granulocytes (a type of white blood cell) are significantly reduced relative to whole-blood levels, which is important for controlling the initial inflammatory response.
• Red Blood Cells (RBCs): The RBC measurement in our final PRP sample is less than 0.1. This is a key quality marker, as high RBC concentrations can be pro-inflammatory and irritant to the joint’s synovial lining.

In my clinic, I analyze these factors for every procedure. I am meticulously tracking the platelet dose, white blood cell contribution, and RBC contamination. This data-driven approach allows me to know exactly which therapeutic agent my patients are receiving and to control it.

Unlocking the Potential of Platelet-Poor Plasma (PPP)

Historically, many of us in the field would prepare PRP and discard the leftover platelet-poor plasma (PPP). However, leading-edge research and my own clinical observations have shown this to be a missed opportunity. The PPP is a rich reservoir of beneficial proteins and growth factors that can be concentrated to create a powerful therapeutic adjunct we call Protein Concentrate (PC).

Even in “platelet-poor” plasma, we still find:

• Platelets (often in significant numbers)
• Alpha-2 Macroglobulin (A2M)
• Hepatocyte Growth Factor (HGF)
• Soluble Tumor Necrosis Factor Receptor (sTNF-R)
• Platelet-Derived Growth Factor BB (PDGF-BB)
• Interleukin-1 Receptor Antagonist (IL-1ra)
• Epidermal Growth Factor (EGF)

By using a specialized fluid reduction filter—a pre-wetted 15-kilodalton filter—we can dehydrate the PPP, reducing its volume by about 75%. This process concentrates all the valuable proteins. The results are clinically significant:

• Human Serum Albumin (HSA): Concentrated to five times baseline.
• sTNF-R: Concentrated to two times baseline.
• IL-1ra: Achieves a 100:1 ratio versus the pro-inflammatory IL-1 beta.
• Scavenged Platelets: We can recover an additional 6 billion platelets from the PPP that would have otherwise been discarded.

The Clinical Significance of Protein Concentrate in Osteoarthritis

The use of PC is particularly transformative in the management of osteoarthritis (OA). The large, beneficial molecules found in PC play a crucial role in disrupting the degenerative cycle of OA.

• Alpha-2 Macroglobulin (A2M): This is a very large protein (720 kilodaltons) that cannot easily migrate from the bloodstream into the synovial fluid of a joint on its own. When we inject it directly into the joint as part of the PC, it acts as a “trap.” It lures and irreversibly binds to catabolic (destructive) enzymes, such as proteases and collagenases, that are responsible for breaking down cartilage. By neutralizing these enzymes, A2M effectively halts a key part of the degenerative process, mitigating the negative feedback loop of chronic inflammation.
• Interleukin-1 Receptor Antagonist (IL-1ra): Interleukin-1 (IL-1) is a primary cytokine driving pain and inflammation in an arthritic joint. IL-1ra is the body’s natural “off switch” for IL-1. By concentrating IL-1ra and injecting it into the joint, we flood the area with these antagonist proteins. They competitively bind to the IL-1 receptors on cartilage cells (chondrocytes) and synovial cells. This physically blocks the pro-inflammatory IL-1 from docking and sending its destructive signals, thereby reducing pain and inflammation.

This dual-action approach—trapping destructive enzymes with A2M and blocking inflammatory signals with IL-1ra—makes PC an invaluable tool in our fight against OA.

Comprehensive Patient Preparation: The Pre-Procedure Discussion

A successful outcome begins long before the needle enters the skin. My initial consultation for an orthobiologic procedure is thorough and typically lasts around 36 minutes. This time is essential to establish the correct diagnosis, discuss all available treatment options (including conventional ones), and collaboratively recommend the most viable path forward for my patient.

Key considerations in our pre-procedure discussion include:

• Steroid Injections: We need to know the timing of any recent steroid injections, as they can negatively impact cellular health and the effectiveness of regenerative treatments.
• Anti-inflammatory Medications (NSAIDs): Patients on daily NSAIDs like ibuprofen or naproxen are a concern. Recent studies suggest that meloxicam may be more compatible with orthobiologic treatments, so I may transition them to it if they cannot cease anti-inflammatory use entirely. Whenever possible, we discontinue NSAIDs and use supplements that help with pain and OA symptoms without disrupting platelet function.
• Hydration: We instruct patients to begin hydrating at least 2 days before their blood draw to ensure adequate vein access and plasma volume.
• Diet: A healthy meal before the procedure is generally recommended. While there is some discussion that intermittent fasting may improve PRP output, the evidence is still emerging and remains controversial.
• Financial Transparency: It’s vital to have an open conversation about the procedure’s cost, as it is not typically covered by insurance. For Medicare patients, an Advanced Beneficiary Notice (ABN) must be signed before treatment.

From a functional medicine perspective, I also run pre-procedure blood work to identify and correct nutritional deficiencies or metabolic imbalances. By optimizing cellular health and metabolism with targeted supplementation, I am stacking the deck in my patient’s favor for the best possible outcome.

Ultrasound-Guided Injection Technique: The Acromioclavicular (AC) Joint

Precision is paramount. For joint injections, ultrasound guidance is the standard of care in my practice. Let’s walk through an injection of the acromioclavicular (AC) joint.

For shoulder procedures, I typically have the patient seated. This provides excellent access for multiple injections (e.g., glenohumeral joint, biceps tendon, supraspinatus), allowing me to work efficiently from back to front. However, one must always be prepared for a potential vasovagal (fainting) response and be ready to move the patient to a side-lying position quickly.

• Technique: I use an out-of-plane approach, entering from posterior to anterior. This allows me to keep the needle path out of the patient’s direct line of sight.
• Procedure: After marking and sterilizing the site, the area is anesthetized. I position the ultrasound transducer so that the AC joint is directly centered on the screen. Using a 25-gauge needle, I triangulate the injection, advancing the needle until I see the bright white tip on the ultrasound screen, right within the V-shaped joint space.
• Injection: Once the needle is perfectly positioned within the joint capsule, I inject the PRP. You can visualize the fluid flowing and distending the small joint space. The AC joint typically holds between 0.6 and 1.1 ccs of fluid.

This precision ensures the entire dose of our carefully prepared PRP and PC is delivered exactly where it is needed most.

The Role of Integrative Chiropractic Care and Post-Procedure Rehabilitation

The injection is a catalyst for healing, but the work doesn’t stop there. A comprehensive post-procedure plan is essential for guiding the regenerative process. This is where integrative chiropractic care becomes indispensable.

• Post-Procedure Discussion: For a comprehensive shoulder treatment, we may place the patient in a sling for 1-2 days for comfort and to protect the joint.
• Laser Therapy (Photobiomodulation): We begin laser therapy the day after the procedure. This technology uses specific wavelengths of light to enhance cellular metabolism, thereby increasing ATP availability (the cell’s energy currency) and nitric oxide release. This accelerates the healing process and shortens the initial inflammatory phase, leading to faster pain relief. I find this to be a critical component of post-injection pain management.
• Rehabilitation Protocols: Proper rehab is non-negotiable. For intratendinous work, a great starting point is to adapt post-surgical rehab protocols for a similar but less severe injury. For example, after a rotator cuff PRP injection, I would use a post-surgical rotator cuff repair protocol, but start the patient at the week-six phase of that protocol.
• Chiropractic Adjustments: As the tissues heal, ensuring proper biomechanics is crucial. Gentle, specific chiropractic adjustments to the thoracic and cervical spine and the scapula can improve overall shoulder girdle function, reduce compensatory stress on the healing joint, and optimize neuromuscular control. This holistic view ensures we are not just treating the site of injury but restoring function to the entire kinetic chain.
• Heat vs. Ice: We advocate for near-infrared light or moist heat. There is growing discussion that ice may slow cellular metabolism and hinder the regenerative cascade. While I prefer to avoid ice, if it is the only modality a patient can tolerate for post-injection pain, I permit its use.

Addressing Clinical Questions: M-Fat, Tumors, and Post-Meniscectomy Pain

During these educational sessions, important questions often arise.

Question: Is there a concern that photobiomodulation (laser therapy) could cause cells from M-Fat (microfragmented adipose tissue) or BMAC (bone marrow aspirate concentrate) to turn into tumors?

Answer: This is an understandable question, but it is not supported by science. Firstly, large-scale studies on M-Fat and BMAC have not shown any significant increase in tumorigenesis. Secondly, the mechanism of photobiomodulation does not involve altering cellular DNA. It simply enhances the cell’s natural metabolic processes by increasing the availability of energy (ATP). It accelerates the existing healing pathways; it does not create new or abnormal ones. I confidently start laser therapy the day after these procedures to manage pain and speed up recovery.

Question: I saw a patient who is having knee pain 12 years after a partial lateral meniscectomy. Is the pain from the meniscus or from arthritis that was kick-started by the surgery?

Answer: This question highlights the need for precision in our language and in our diagnoses. It is not accurate to say that arthroscopic surgery, in general, “kick-starts” or accelerates arthritis. However, a meniscectomy (the removal of meniscal tissue) absolutely does. The meniscus is the knee’s shock absorber. When you cut out a piece of it, you increase contact pressures and point loading on the articular cartilage, which directly accelerates the arthritic process.

Therefore, it is entirely expected that 12 years after a lateral meniscectomy, a patient would have accelerated arthritic changes. The pathology is now an arthritic knee. The treatment should be selected based on the grade of that arthritis. Is it mild, moderate, or severe? Is there a concomitant bone marrow lesion? Is there a new meniscal tear? This is why a thorough diagnosis using tools such as ultrasound and MRI is required to personalize the approach. In contrast, a meniscal repair, augmented with PRP or other biologics, is chondroprotective because it restores the joint’s natural cushioning.

My treatment for this patient would focus on the arthritis. If he had a diminutive meniscus with no new tear, injecting into the meniscus would not be the primary goal. The goal is to treat the intra-articular arthritic environment.

By integrating these advanced orthobiologic techniques with the foundational principles of chiropractic and functional medicine, we can offer our patients a truly comprehensive and personalized path to healing, moving beyond symptom management to true tissue regeneration and functional restoration.

References

Cuéllar, J. M., Cuéllar, V. G., & Scuderi, G. J. (2016). α2-Macroglobulin: A novel inhibitor of cartilage catabolism. The Journal of Knee Surgery, 29(06), 473–478. https://doi.org/10.1055/s-0036-1584200

Hassan, W., & Kehailia, M. (2023). Intra-articular platelet-rich plasma versus hyaluronic acid injections in knee osteoarthritis: A systematic review and meta-analysis. Cureus, 15(10), e47525. https://doi.org/10.7759/cureus.47525

Mautner, K., Colberg, R. E., Malanga, G., Borg-Stein, J. P., Harmon, K., Draeger, R. W., Bowen, J., & New AMSSM Task Force, PRP. (2019). Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: A multicenter, retrospective review. PM&R, 11(2), 169-179. https://doi.org/10.1016/j.pmrj.2018.06.009

Meheux, C. J., McCulloch, P. C., Lintner, D. M., Varner, K. E., & Harris, J. D. (2016). Efficacy of intra-articular platelet-rich plasma injections in knee osteoarthritis: a systematic review. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 32(3), 495–505. https://doi.org/10.1016/j.arthro.2015.08.005

Wood, S., Kark, L. R., & Sanchetee, P. (2022). The use of protein concentrate in the management of musculoskeletal conditions: A narrative review. Regenerative Medicine, 17(12), 929-940. https://doi.org/10.2217/rme-2022-0056

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