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Platelet Rich Plasma (PRP)

Platelet-Rich Plasma in the Treatment of Low Back Pain caused by Degenerative Disc Disease

The efficacy of platelet-rich plasma (PRP) in the treatment of low back pain remains largely unknown. Up until now, very few studies have looked at whether PRP can effectively treat low back pain caused by degenerative conditions. When considering back pain that is caused by a degenerating disc, common treatment options standardly include physical therapy, medications such as non-steroidal anti-inflammatory (NSAIDs), corticosteroid injections, radiofrequency ablation and in some cases, surgery. Unfortunately, while these treatment modalities may lessen the severity of clinical symptoms, none target the underlying pathology or as we all are looking for, reverse the aging and degenerative process.

A prospective, double blind randomized control trial published by Taukli-Wosornu et al (2016) analyzed 47 patients (27 in treatment group, 18 in control group) with degenerative disc disease as confirmed by provocative discography. Those in the treatment arm of the study received a single injection of platelet rich plasma (PRP) versus the control group who received an injection of a contrast agent into the painful disc. PRP (1-2 mL) was injected in discs determined to have concordant pain. Outcomes were based on the Functional Rating Index (FRI), Numeric Rating Scale (NRS) for pain, SF-36 (pain and physical function domains), and the modified North American Spine Society Outcome Questionnaire (NASS). Data was collected at baseline, one week, four weeks, eight weeks, six months and one year. The follow-up rate was reported to be 92%. No adverse of events including infection, neurologic injury or progressive herniation was reported.

After eight weeks of follow-up, the treatment group that received PRP injections, had statistically significant improvements in regards to pain, function, and overall satisfaction when compared to the control group. Functional scores remained significantly improved through 1 year of treatment. It should be noted that follow-up of the control group was only 8 weeks. No follow-up radiologic studies were conducted to determine if there were any morphologic changes.

While this study does provide data suggesting PRP as safe, efficacious option for those who suffer from low back pain due to degenerative disc disease, this was a relatively small sample size and the three questions of who is an appropriate candidate for this treatment, what PRP concentration is needed to have a therapeutic effect, and how many injections are needed, remain to be answered.

Tuakli-Wosornu YA1Terry A2Boachie-Adjei K3Harrison JR4Gribbin CK5LaSalle EE6Nguyen JT7Solomon JL8Lutz GE9.
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study.
PMR. 2016 Jan;8(1):1-10; quiz 10. doi: 10.1016/j.pmrj.2015.08.010. Epub 2015 Aug 24.

Platelet Rich Plasma vs. Cortisone Injection for Partial Rotator Cuff Tears

A recent study published in the European Journal of Orthopaedic Surgery and Traumatology (Aug 20, 2016) compared cortisone injections to Platelet Rich Plasma injections for patients with a painful partial rotator cuff tear. This was a prospective, randomized controlled study that enrolled 40 patients with a symptomatic (painful) rotator cuff tear. Patients were evaluated prior the injection and at specific time intervals (6 weeks, 3 months, and 6 months) following the injection. Standardized outcome measures including the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), the Constant-Murley Score (CMS), Simple Shoulder Test (SST) and Visual Analog Scale (VAS) were utilized.

The results of the study showed that both the cortisone injection group and PRP group both received significant clinical improvement following an injection. The PRP group had superior results that were statistically significant at 12 weeks with all outcome measures. At 6 months after the injection, there was no statistical difference between the groups.

The authors of this study concluded that subacromial PRP injection should be considered a good alternative to cortisone injections especially in light of the potential complications associated with corticosteroids.

The results of this study mirror findings from a previous investigation of 50 patients by von Wehren et al (Knee Surg Sports Trauma Arthro May 2015). The theory behind the results, relates to some evidence that the platelets may help provide revascularization to the injured rotator cuff tendon.

More evidence is needed to fully support the use of PRP for the indication of a symptomatic partial rotator cuff tear. The current evidence does suggest a viable alternative to corticosteroid injections for short term relief with a lower risk of complications.

A2M: The next generation of non-surgical treatment for arthritis

Stem cell therapy and Platelet Rich Plasma (PRP) therapies are becoming increasingly popular for the treatment of many musculoskeletal degenerative disorders. While appearing promising as a means of decreasing pain and in some cases reversing disease, there remains many unknowns in regards to the ideal concentrations, treatment protocols, and long term effects of these treatments.

Add Alpha-2-macroglobulin to the short list of treatments that fall under the umbrella of regenerative medicine. Alpha-2-macroglobulin or A2M is a naturally occurring protein in the body that inhibits proteases (enzymes) that cause deterioration of cartilage which leads to arthritis.

Three protein classes which include cytokines, matrix metalloproteinases, and ADAMTS that have been identified as the culprits that cause the breakdown of cartilage cells leading to damage of joint surfaces. A2M has been shown to inhibit or inactivate these chemicals. Researchers have found that natural concentrations of A2M in the body may not be sufficient enough to protect the joints from the development of osteoarthritis. In response, a super concentrated form of A2M has been developed which can be injected into the joints. In fact, clinical trials of A2M (phase I/II) were approved by the FDA and began in May 2015. Data from this double blind, efficacy and safety study was recently reported and phase III trials are soon to begin.

At present, A2M is only being tested on patients with osteoarthritis of the knee. Unlike cortisone treatments, A2M does not appear to have negative side effects. Furthermore, A2M protects the joint surface and decreases inflammation.

As a new biologic treatment, targeted at treating osteoarthritis, A2M therapy has the potential to one day replace conventional treatments.

References:

Wang S et al. Identification of alpha2-macroglobulin as a master inhibitor of cartilage degrading factors that attenuates the progression of posttraumatic osteoarthritis. Arthritis Rheumatol. 2014 Jul; 66(7): 1843-1853.

http://cytonics.com/news/

http://finance.yahoo.com/news/cytonics-announces-recombinant-a2m-variants-194916921.html

The Effectiveness of Platelet Rich Plasma (PRP) in Treating Tendinopathies

A recent study published in PLOS ONE evaluated the effectiveness of Platelet Rich Plasma (PRP) in the treatment of degenerative tendinopathies. This study by Wesner et al was a pilot study utilizing both a randomized control trial and synchronous observational cohort study. The randomized group included 9 patients with a rotator cuff tendinopathy and were assigned to either PRP or placebo. The observational cohort consisted of 178 participants with various tendinopathies. Subjects who received PRP were given an injection of 4 mL into the supraspinatus and/or infraspinatus tendons (“Rotator Cuff”). Participants in the control group received 4 mL of saline. All patients were given a standardized home based exercise program (daily) for 3 months.

Study participants were evaluated based on changes in pain scores, disability index scores, and pre/post MRI findings at 3 months and 6 months. While the sample size was small in the randomized trial (N=9), the mean improvement for pain scores in the PRP group was clinically important, but was not for the placebo group. Five out of 7 participants in the PRP group (71%) had noted improvement in MRI findings after the PRP injection.

The second part of the investigation consisted of a retrospective observational cohort study. Participants received 3 to 8 mL of PRP into the affected tendon along with a standardized home exercise program. Patients in this arm of the study were evaluated at 1, 2 and 3 months following PRP injection. Pre-injection VAS (visual analog scale) pain scores were compared to follow-up scores. Of concern with this study, 65 participants (36.5%) were excluded due to incomplete data or loss of follow-up information. Statistical significance and clinical important differences were seen between pre-injection VAS scores and follow-up.

Overall, the authors presented data was positive when considering the use of PRP for tendinopathy. However, caution must be exercised with interpreting both components of this study as the number of participants in the randomized trial (N=9) was very small and there are some major concerns for loss of study participants and varying injection protocol. Statistical testing was also limited.

References:

Wesner M, Defreitas T, Bredy H, et al. A Pilot Study Evaluating the Effectiveness of Platelet-Rich Plasma Therapy for Treating Degenerative Tendinopathies: A Randomized Control Trial with Synchronous Observational Cohort. PLOS ONE. 2016 Feb 5.

Platelet-Rich Plasma (PRP) Injections for the treatment of knee osteoarthritis

A new study published in the American Journal of Sports Medicine looked at the use of Platelet Rich Plasma (PRP) injections for osteoarthritis of the knee both from a safety and efficacy standpoint.

This was a small study consisting of 30 patients who received an intra-articular PRP injection in the knee consecutively for 3 weeks. Specifically, 3 to 8 mL of PRP was injected. Patients in the control group received 3 intra-articular injections of saline. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score was used to assess outcome.

The results showed that those who received the PRP injections had a 78% improvement from baseline whereas the controls only had a 7% improvement at 12 months. WOMAC scores improved to a greater degree in the PRP group than controls starting at 2 weeks. This effect lasted throughout the duration of the study.

Overall there were no adverse events associated with the PRP injections. As this study was sanctioned by the Food and Drug Administration (FDA), the small study size was mandated to evaluate for safety. The results of this study support prior observations by Duymus et al (Knee Surgery Sports Traumatology Arthroscopy 2016) and Kavadar et al (Journal of Physical Therapy Science 2015). A recent systematic review by Meheux et al (Arthroscopy 2016) which included 6 published studies with a minimum of 6 months of follow-up also reported significant clinical efficacy for PRP injections in the treatment of knee osteoarthritis up to 12 months.

References:

Smith P. Intra-articular autologous conditioned plasma injections provide safe and efficacious treatment for knee osteoarthritis: an FDA-sanctioned, randomized, double-blind, placebo-controlled trial. American Journal of Sports Medicine. 2016. Apr 44(4): 884-891.

Duymus TM et al. Choice of intra-articular injection in treatment of knee osteoarthritis: platelet-rich plasma, hyaluronic acid or ozone options. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. Apr 7.

Kavadar G. et al. Effectieness of platelet-rich plasma in the treatment of moderate knee osteoarthritis: a randomized prospective study. Journal of Physical Therapy Science. 2015: Dec 27(12): 3863-3867.

Meheux CJ et al. Efficacy of Intra-articular Platelet-Rich Plasma Injections in Knee Osteoarthritis: A systematic review. Arthroscopy. 2016. Mar 32(3): 495-505.

Platelet Rich Plasma (PRP) in the Treatment of a Frozen Shoulder

A recent case report published in the Archives of Bone and Joint Surgery has shown positive results for the use of Platelet Rich Plasma (PRP) in the treatment of a frozen shoulder. The case was a 45 year old man with adhesive capsulitis (frozen shoulder). He underwent PRP injections beginning after 7 months of symptoms. Following the first treatment, he reported a 60% improvement in pain during the day and had no pain at night. His range of motion reportedly improved significantly and a 70% improvement in function (based on the DASH – Disabilities of the Arm, Shoulder, and Hand questionnaire) was noted. The patient did receive a second PRP injection one month later.

This is the first reported use of PRP in the treatment of a frozen shoulder. A frozen shoulder or adhesive capsulitis refers to a condition in which the shoulder joint tightens up due to the capsule becoming inflamed resulting in decreased and painful range of motion.

Adhesive capsulitis usually be found in patients in the 40 to 70 year old range with a slightly higher percentage of women affected. Hormonal changes in women are believed to play a part in this.

The true underlying cause of adhesive capsulitis remains unknown. It is known that this condition can result from a traumatic event or surgery. Diabetics are five times more likely to develop this condition. This is especially true amongst insulin dependent diabetics. It is believed that the interaction of glucose molecules sticking to collagen fibers within the joint capsule may lead to or contribute to this condition.

Treatment of a frozen shoulder has traditionally focused around extended courses of physical therapy to preserve mobility of the shoulder. Anti-inflammatory medications (NSAIDs) and corticosteroids are also commonly used to reduce inflammation. Surgery is usually reserved as a last measure. A manipulation of the shoulder under anesthesia and/or a capsular release may be performed. Results have been shown to vary considerably.

Recovery is often slow, taking anywhere from a year or more.

Both prolotherapy and PRP treatments have been shown to provide positive results in the treatment of many soft tissue disorders. Several other published studies have shown the potential effectiveness of PRP in the management of rotator cuff disorders. While no solid conclusions can be drawn from this single case report, it does provide us with useful information and further investigational studies are needed to assess the efficacy of PRP in the treatment of a frozen shoulder.

References:

Aslani H, Nourbakhsh ST, Zafarani Z, et al. Archives of Bone and Joint Surgery. 2016. Jan; 4(1): 90-93.

The use of PRP in orthopaedics: AAOS Now review article

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Platelet Rich Plasma (PRP) is the headline story of this month’s edition of The American Academy of Orthopaedic Surgeons (AAOS) publication AAOS Now. The article titled, “PRP: Does it Do Anything?” was written by senior author, Scott Duncan, M.D., MPH, MBA, who is the current chairman of the Department of Orthopaedic Surgery at Boston University Medical Center along with three orthopaedic surgical residents. As presented in the article, the optimal platelet concentration for PRP is believed to be 3 to 5 times that of whole blood. This does appear to be consistent with other published review articles. Concentrations higher than this may actually pose a detriment to healing. Previously discussed by PRPPROLOTHERAPYTAMPA and duplicated in this article, the literature continues to slowly expand with high quality investigations, but the biggest problem remains in trying to compare studies. Significant differences in PRP preparation, injection technique and treatment protocols for a specific musculoskeletal condition presents challenges when trying to assess the evidence. In some cases, published studies have had a sound methodological plan, but have had small samples sizes. PRP has been used to treat a wide array of disorders, but again we have not yet truly defined what it is clinically appropriate for.

This article by Parisien et al does discuss the use of PRP for conditions including osteoarthritis, fracture care, lumbar fusion, and ACL reconstruction. The potential benefits of PRP along with selected studies including randomized clinical trials (level I and II evidence) in some cases, were presented but the general conclusion is that limited evidence currently exists to support use for these specific conditions. It was noted that there is some benefit shown for the application of PRP into the patellar and tibial plug donor sites in ACL reconstruction. Two quoted studies were used in this assessment which have shown improved postoperative VAS scores and decreased patella tendon gap on MRI 6 months post-operatively.

In the opinion of PRPPROLOTHERAPYTAMPA, this review article published in AAOS Now does paint a realistic picture of the current state of PRP use in orthopaedics. PRP is widely used to treat a multitude of soft tissue and bony disorders and may be an effective alternative treatment but we still do not have firm evidence to support this. Standardization of PRP preparations, administration, injection protocols and outcome measures are imperative if we wish to be able to define effectiveness and eventually produce evidenced based treatment algorithms. The overall conclusions published by the authors of this paper are very similar to that of the consensus drawn from the 2011 AAOS Now PRP forum.

References:

  • Parisien RL, Trofa DP, Dashe J, Duncan SFM. PRP: Does it do anything? AAOS Now. February 2016.

Intradiscal Lumbar Platelet Rich Plasma Injections for Low Back Pain

Several anecdotal and case reports have previously appeared in the literature regarding the intradiscal use of Platelet Rich Plasma (PRP) for low back pain.

Within the last 6 weeks, two recent studies have been published evaluating the use of Platelet-Rich Plasma in the treatment of low back. Tuakli-Wosornu YA et al (PMR 2016) looked at single injections of PRP into symptomatic degenerated lumbar discs in 47 patients. This was a prospective, blinded randomized controlled study. Data collected included pain, physical function, and patient satisfaction scores at initial visit and up to 1 year. The authors did utilize validated outcome measures. After 8 weeks of follow-up, statistically significant improvements were seen in pain scores, function scores, and patient satisfaction. No adverse events were reported. Methodologically, this was a well-planned and reported study, however, outcomes between the PRP treatment group and controls were only measured out to 8 weeks.

In another recent study by Levi D et al (Pain Med 2015), 22 patients received intradiscal PRP for chronic discogenic low back pain. This was a prospective trial evaluating a one injection protocol. Outcomes were based on Oswestry Disability Index (ODI) scores and Visual Analog Scores (VAS). Clinical success was defined if a patient achieved at least 50% improvement in both the ODI and VAS scores. After 1 month, 14% had achieved clinical success. This number grew to 47% at the 6 month mark.

Again, these results are encouraging but more well controlled trials with larger number of patients and longer follow-up periods is needed to fully evaluate the effectiveness of this treatment.

References:

Rotator Cuff Tendinopathies: A case for regenerative injection therapies?

 Rotator Cuff Tendinopathies: A case for regenerative injection therapies?

A painful shoulder is one of the most common complaints seen by orthopaedists.  Athletes who participate in repetitive overhand throwing sports such as baseball, basketball, and volleyball are at increased risk for shoulder injuries.  The same holds true for those who work in an occupation requiring overhead activity.  Pain and dysfunction to the shoulder(s) can also arise from normal aging.  The term rotator cuff syndrome is often used when referring to tearing within the rotator cuff tendons.

 

Anatomically, the rotator cuff is made up of four tendons: supraspinatus, infraspinatus, subscapularis and the teres minor.  These tendons originate along the scapula and attach at various points along the head of the humerus.  Within the shoulder there are several bursa which normally facilitate smooth gliding of the tendons and muscles.

Many painful conditions related to overuse that encompass the rotator cuff tendons and surrounding soft tissues, are commonly referred to as rotator cuff tendinopathy.  Rotator cuff tendinopathy is a very complex, multifactorial process involving both intrinsic (within a tendon) and extrinsic (outside of a tendon) factors.  Clinically, patients often complain of pain with specific motions such as reaching overhead, with lifting, and often at night when sleeping on the affected shoulder. Loss of normal range of motion may also be present with forward elevation of the shoulder and with abduction (moving arm away from the body).  Weakness and further loss of motion often result from disease progression. These symptomatic complaints may be caused by underlying degenerative changes within the tendons resulting in mechanical overload. Additionally, compression on the tendon(s) caused by bony structures may also accompany the forementioned intrinsic factors.

 

The combination of a good detailed patient history of complaints, a sound physical examination, and an MRI of shoulder can help the physician provide the proper clinical diagnosis and direct treatment.  Traditionally, treatment for tendinopathies has included NSAIDs, physical therapy, and corticosteroid injections.  Many can be successfully managed utilizing these non-surgical treatments.  As previously mentioned, rotator cuff tendinopathy is a complex condition and in some cases traditional treatments fail to help improve symptoms.   While there are varying surgical options depending on the specific underlying issue(s), the risks of the procedure and outcomes must be weighed.

In the last decade, the use of regenerative injection therapies for rotator cuff tendinopathies, has been developed and continues to evolve. Prolotherapy, Platelet-Rich Plasma (PRP), and even stem cell therapies have been applied.  Presently there is limited data to support regenerative injection therapies as a part of a standard medical treatment plan for rotator cuff tendinopathies.  However, its use has been reported with increasing frequency by the media among professional athletes.

A few randomized controlled trials and prospective studies utilizing Prolotherapy and/or PRP have been published in the last few years. Outcome measures have focused on pain scales, patient satisfaction, and disability indexes (Western Ontario Rotator Cuff Index, Shoulder Pain and Disability Index).  The results for the most part have been positive.  Further studies to show efficacy are needed.

 

References:

Bertran H, Reeves KD, Bennett CJ, Bicknell S, Cheng AL. Dextrose Prolotherapy versus Control Injections in Painful Rotator Cuff Tendinopathy. Arch Phys Med Rehabil. 2015 Aug 21.

Scarpone M, Rabago D, Snell E, Demeo P, Ruppert K, Pritchard P, Arbogast G, Wilson JJ, Balzano JF. Effectiveness of Platelet-rich Plasma Injection for Rotator Cuff Tendinopathy: A Prospective Open-label Study. Glob Adv Health. Med. 2013 Mar;2(2):26-31.

 

 

 

Regenerative Injection Therapies for Hip Bursitis

Regenerative Injection Therapies for Hip Bursitis

Trochanteric bursitis, or hip bursitis, as it is commonly referred to as, is a common orthopedic condition that normally is self-limiting. The condition refers to inflammation of a fluid filled sac (bursa) that sits along the outside of the hip. This area, known as the greater trochanter, is formed from the upper end of the femur bone. This is attachment point for muscles and tendons and is an area where friction may develop. The body’s response to friction is to produce bursa tissue.

What causes bursitis and what are the common symptoms?

Trochanteric bursitis typically develops gradually. Injury to the lateral (outside) part of the hip, an overuse injury such as standing for prolonged periods of time, poor posture, lower spinal related disorders, calcium deposits in the surrounding tendons, a sudden change in a workout or training routine, a leg length discrepancy, and other medical conditions such as rheumatoid disease, gout, or thyroid disease can cause hip bursitis. Bursitis also may develop following a hip replacement.

Pain usually develops along the outside of the hip and may begin to radiate downward. There may be tenderness along the bony ridge that forms the greater trochanter. There may be pain with standing from a seated position or with stair climbing. As the disease progresses, increased stiffness within the hip may lead to a limp. Sufferers of hip bursitis often complain of increased pain at night while lying on the affected side.

Treatment for trochanteric bursitis may include activity modification, rest, non-steroidal anti-inflammatory (NSAID) medication, and physical therapy and corticosteroid injections. As systematic review published by Lustenberger et al (2011) found that as many as 33% of patients treated required a second corticosteroid injection to alleviate symptoms of hip bursitis while some had 5 injections!

Surgical management of trochanteric bursitis may be recommended for those who have tried and failed all of the conservative treatment options and still remain symptomatic.
A 2014 study published by the American Academy of Orthopaedic Surgeons (AAOS), compared a single corticosteroid injection to a single platelet rich plasma (PRP) injection for chronic hip bursitis. Twenty patients were included in each group. Outcomes were measured based on validated outcome questionnaires that looked at pain levels, function, and stiffness. Patients treated with PRP had greater improvements in post-treatment scores and had lasting effect (at 1 year after injection) whereas those treated with a cortisone injection had scores that returned back to pretreatment levels within 3 months. The results of the small study appear promising, but further well controlled studies are needed to fully delineate the effectiveness of PRP injections for hip bursitis.
At present, the medical literature is very limited on studies looking at PRP injections and Prolotherapy for hip bursitis. There are a few case reports about patients being successfully treated with either PRP or Prolotherapy. Both PRP and Prolotherapy appear safe and may offer suffers long lasting relief.

Hip bursitis is one of the most common causes of pain in the adult population. It is normally a condition that can be treated non-surgically for most. Unfortunately, some will not improve with treatment resulting in a chronic condition that is much harder to cure. Regenerative injection therapies such as PRP and Prolotherapy should be considered if clinical improvements are not seen early in the treatment process.

References:
Lustenberger DP, Ng, YV, Best TM, Ellis TJ. Efficacy of Treatment of Trochanteric Bursitis: A Systematic Review. Clin J Sports Med. 2011 Sept: 21(5): 447-453.
Monto RR. Paper #778. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 11-15, 2014; New Orleans