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Levine OP, Kondapi K, Tjong VK, Gohal C. Postinjection protocols following platelet-rich plasma administration for knee osteoarthritis: A systematic review. PM R 2024. [PMID: 38525952 DOI: 10.1002/pmrj.13139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/26/2023] [Accepted: 01/08/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVE Platelet-rich plasma (PRP) use in treating orthopedic conditions has increased, yet evidence of its clinical efficacy is inconsistent and limited by heterogeneity in osteoarthritis (OA) severity, PRP preparations and protocols, and clinical outcome measurement. This review aims to characterize the variations in postinjection protocols in studies assessing the clinical efficacy of PRP for knee OA. LITERATURE SURVEY A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search from database inception to February 2023 of CINAHL, MEDLINE, and EMBASE was conducted. METHODOLOGY Article screening, data extraction, and risk of bias assessments were completed in duplicate by two reviewers. Primary outcomes were presence/absence and timing of the following postinjection protocol components: nonsteroidal anti-inflammatory drug (NSAID) restrictions, non-NSAID analgesic and cryotherapy use, immediate knee flexion/extension, immediate rest, activity restriction, return-to-activity guidelines, and rehabilitation protocols. A descriptive analysis was used to analyze the data. Given study heterogeneity, a meta-analysis was not performed. SYNTHESIS A total of 187 studies were included for analysis. Half of all studies (51.9%) excluded patients due to preinjection NSAID use, most often within 5 days of blood sampling or injection. Postinjection NSAID restriction was included in 42.8% of studies, ranging from 1 to 1800 days. Few studies (19.4%) that permitted non-NSAID analgesia restricted their use prior to clinical assessments. Postinjection immediate flexion, extension, and immobilization were rarely (8.6%) mentioned. Activity restriction was included in a third of studies (35.3%), with the most frequent length of restriction being 1 day. Postinjection return-to-activity protocols were less common (20.3%), usually with a "gradual" and/or "as tolerated" recommendation. A minority of studies (16.0%) reported physical therapy protocols and the vast majority (93.3%) were home based. CONCLUSION Significant heterogeneity remains in post-PRP injection protocols, with unclear consensus regarding optimal recommendations and limited rationale for the protocols outlined. Further study is necessary to compare protocols directly and to determine which pre- and postinjection recommendations can result in optimal outcomes.
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Affiliation(s)
- Oscar Paul Levine
- Department of Orthopaedic Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Koushik Kondapi
- Department of Orthopaedic Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Vehniah Kristin Tjong
- Department of Orthopaedic Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Chetan Gohal
- Rothman Orthopaedic Institute, New York City, New York, USA
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Nelson PA, George T, Bowen E, Sheean AJ, Bedi A. An Update on Orthobiologics: Cautious Optimism. Am J Sports Med 2024; 52:242-257. [PMID: 38164688 DOI: 10.1177/03635465231192473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Orthobiologics are rapidly growing in use given their potential to augment healing for multiple musculoskeletal conditions. Orthobiologics consist of a variety of treatments including platelet-rich plasma and stem cells that provide conceptual appeal in providing local delivery of growth factors and inflammation modulation. The lack of standardization in nomenclature and applications within the literature has led to a paucity of high-quality evidence to support their frequent use. The purpose of this review was to describe the current landscape of orthobiologics and the most recent evidence regarding their use.
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Affiliation(s)
- Patrick A Nelson
- University of Chicago Department of Orthopedic Surgery, Chicago, Illinois, USA
| | - Tom George
- Northshore University Healthcare System, Evanston, Illinois, USA
| | - Edward Bowen
- Weill Cornell Medicine, New York City, New York, USA
| | - Andrew J Sheean
- San Antonio Military Medical Center, Department of Orthopedic Surgery, San Antonio, Texas, USA
| | - Asheesh Bedi
- Northshore University Healthcare System, Evanston, Illinois, USA
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Aljefri AM, Brien CO, Tan TJ, Sheikh AM, Ouellette H, Bauones S. Clinical Applications of PRP: Musculoskeletal Applications, Current Practices and Update. Cardiovasc Intervent Radiol 2023; 46:1504-1516. [PMID: 37783774 DOI: 10.1007/s00270-023-03567-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/14/2023] [Indexed: 10/04/2023]
Abstract
Musculoskeletal tissues are often subjected to deleterious effects stemming from traumatic injuries or degenerative pathologies, which can impede the body's natural repair response. The advent of regenerative medicine has emerged as a promising therapeutic approach in modern patient care. Among the interventions in this cutting-edge field, platelet-rich plasma (PRP) and cell-based therapies, such as mesenchymal stem cells, have garnered significant attention. In this article, we endeavor to provide an overview of the current practices and recent developments in PRP therapy, with a particular emphasis on the clinical applications for musculoskeletal pathologies.
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Affiliation(s)
- Ahmad M Aljefri
- Department of Musculoskeletal and Interventional Radiology, King Fahad Medical City, 11525, Riyadh, Saudi Arabia
| | - Cormac O Brien
- Department of Radiology, Vancouver General Hospital/University of British Columbia, Vancouver, BC, Canada
| | - Tien Jin Tan
- Department of Radiology, Changi General Hospital, Singapore, Singapore
| | - Adnan M Sheikh
- Department of Radiology, Vancouver General Hospital/University of British Columbia, Vancouver, BC, Canada
| | - Hugue Ouellette
- Department of Radiology, Vancouver General Hospital/University of British Columbia, Vancouver, BC, Canada
| | - Salem Bauones
- Department of Musculoskeletal and Interventional Radiology, King Fahad Medical City, 11525, Riyadh, Saudi Arabia.
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Dorogin J, Townsend JM, Hettiaratchi MH. Biomaterials for protein delivery for complex tissue healing responses. Biomater Sci 2021; 9:2339-2361. [PMID: 33432960 DOI: 10.1039/d0bm01804j] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tissue repair requires a complex cascade of events mediated by a variety of cells, proteins, and matrix molecules; however, the healing cascade can be easily disrupted by numerous factors, resulting in impaired tissue regeneration. Recent advances in biomaterials for tissue regeneration have increased the ability to tailor the delivery of proteins and other biomolecules to injury sites to restore normal healing cascades and stimulate robust tissue repair. In this review, we discuss the evolution of the field toward creating biomaterials that precisely control protein delivery to stimulate tissue regeneration, with a focus on addressing complex and dynamic injury environments. We highlight biomaterials that leverage different mechanisms to deliver and present proteins involved in healing cascades, tissue targeting and mimicking strategies, materials that can be triggered by environmental cues, and integrated strategies that combine multiple biomaterial properties to improve protein delivery. Improvements in biomaterial design to address complex injury environments will expand our understanding of both normal and aberrant tissue repair processes and ultimately provide a better standard of patient care.
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Affiliation(s)
- Jonathan Dorogin
- Knight Campus for Accelerating Scientific Impact, University of Oregon, 6321 University of Oregon, Eugene, OR 97401, USA.
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Rehabilitation Nutrition for Injury Recovery of Athletes: The Role of Macronutrient Intake. Nutrients 2020; 12:nu12082449. [PMID: 32824034 PMCID: PMC7468744 DOI: 10.3390/nu12082449] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 12/15/2022] Open
Abstract
An adequate and balanced diet is of utmost importance in recovery and rehabilitation. "Rehabilitation nutrition" for injury recovery of athletes is similar to sports nutrition, except for the differences that concern the prevention of the risk or presence of sarcopenia, malnutrition, or dysphagia. Rehabilitation nutrition also aims, combined with training, to an adequate long-term nutritional status of the athlete and also in physical condition improvement, in terms of endurance and resistance. The aim of this paper is to define the proper nutrition for athletes in order to hasten their return to the sports after surgery or injury. Energy intake should be higher than the energy target in order to fight sarcopenia-that is 25-30 kcal/kg of body weight. Macro- and micro-nutrients play an important role in metabolism, energy production, hemoglobin synthesis, lean mass and bone mass maintenance, immunity, health, and protection against oxidative damage. Nutritional strategies, such as supplementation of suboptimal protein intake with leucine are feasible and effective in offsetting anabolic resistance. Thus, maintaining muscle mass, without gaining fat, becomes challenging for the injured athlete. A dietary strategy should be tailored to the athlete's needs, considering amounts, frequency, type and, most of all, protein quality. During rehabilitation, simultaneous carbohydrates and protein intake can inhibit muscle breakdown and muscle atrophy. The long-term intake of omega-3 fatty acids enhances anabolic sensitivity to amino acids; thus, it may be beneficial to the injured athlete. Adequate intakes of macronutrients can play a major role supporting athletes' anabolism.
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Auriemma MJ, Tenforde AS, Harris A, McInnis KC. Platelet-rich plasma for treatment of chronic proximal hamstring tendinopathy. Regen Med 2020; 15:1509-1518. [PMID: 32419631 DOI: 10.2217/rme-2019-0105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Aim: To determine whether platelet-rich plasma (PRP) can successfully treat symptoms associated with proximal hamstring tendinopathy. Materials & methods: Charts were retrospectively reviewed of patients with a diagnosis of chronic proximal hamstring tendinopathy who underwent an ultrasound-guided leukocyte-rich PRP injection to assess reported outcomes at baseline and final follow-up post-intervention. Results: In 22 patients with a mean age of 48.7 years and mean symptom duration of 26.5 months, mean Numeric Pain Rating Scale and Victorian Institute of Sport Assessment Scale for Proximal Hamstring Tendinopathy subscores demonstrated statistically significant improvements (p < 0.05) at a mean of 7.91 months follow-up. Sixty-eight percent of patients demonstrated ≥50% reduction of pain. Conclusion: Pain and functional outcomes improved following injection of PRP.
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Affiliation(s)
- Michael J Auriemma
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.,Spaulding Rehabilitation Hospital, 300 1st Ave, Charlestown, MA 02129, USA
| | - Adam S Tenforde
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.,Spaulding Rehabilitation Hospital, 300 1st Ave, Charlestown, MA 02129, USA
| | - Adam Harris
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.,Spaulding Rehabilitation Hospital, 300 1st Ave, Charlestown, MA 02129, USA
| | - Kelly C McInnis
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.,Spaulding Rehabilitation Hospital, 300 1st Ave, Charlestown, MA 02129, USA.,Department of Sports Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
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Townsend C, Von Rickenbach KJ, Bailowitz Z, Gellhorn AC. Post-Procedure Protocols Following Platelet-Rich Plasma Injections for Tendinopathy: A Systematic Review. PM R 2020; 12:904-915. [PMID: 32103599 DOI: 10.1002/pmrj.12347] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 01/13/2020] [Accepted: 01/15/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Platelet-rich plasma (PRP) has been increasingly studied as a treatment for tendinopathy. Many factors may influence outcomes after PRP, including different protocols following administration. It was hypothesized that there would be heterogeneity in post-PRP protocols. LITERATURE SURVEY A systematized review of the literature on post-PRP protocols for tendinopathy was conducted using an electronic search of MEDLINE and Embase databases through September 2018. METHODOLOGY After duplicates were removed, English language articles involving adult patients who received PRP for tendinopathy were reviewed. Exclusion criteria included studies with fewer than 10 patients, PRP used to treat pathology other than tendinopathy, multiple protocols in one study, and surgical settings. Protocol specifics were extracted including nonsteroidal anti-inflammatory drugs (NSAID) restrictions before and after injection, postinjection restrictions on movement and weight bearing, use of orthoses, activity modifications, and postinjection rehabilitation protocols. Given limitations in the data, a meta-analysis was not performed. SYNTHESIS Eighty-four studies met inclusion criteria. Following PRP injection, weight-bearing restrictions were mentioned rarely (12% of protocols). Orthosis use was uncommon overall (18%) but more common in Achilles tendinopathy protocols (53%). The majority of protocols instituted a period of stretching (51%) and strengthening (54%). Stretching programs generally began 2-7 days following injection, and strengthening programs began within 2-3 weeks. Preinjection NSAID restriction was reported rarely (20%), whereas postinjection NSAID restriction was more common (56%), with a typical restriction of greater than 2 weeks (38%). Return to play or full activity was reported in 42% of protocols, most commonly at 4-6 weeks following injection. CONCLUSION Although the clinical effectiveness of PRP remains controversial, even less is known about the effect of post-PRP protocols, which may affect the outcomes attributed to PRP itself. No studies directly compare post-PRP protocols, and the protocols studied demonstrate substantial heterogeneity. Some consensus regarding post-PRP protocols exists, although the rationale for these recommendations is limited.
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Affiliation(s)
- Christine Townsend
- Department of Rehabilitation Medicine, New York-Presbyterian Rehabilitation Medicine, Weill Cornell Medical College & Columbia University Irving Medical Center, New York, NY, USA
| | - Kristian J Von Rickenbach
- Department of Rehabilitation Medicine, New York-Presbyterian Rehabilitation Medicine, Weill Cornell Medical College & Columbia University Irving Medical Center, New York, NY, USA
| | - Zachary Bailowitz
- Department of Rehabilitation Medicine, New York-Presbyterian Rehabilitation Medicine, Weill Cornell Medical College & Columbia University Irving Medical Center, New York, NY, USA
| | - Alfred C Gellhorn
- Department of Rehabilitation, Weill Cornell Medicine, New York, NY, USA
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Kolber MJ, Purita J, Paulus C, Carreno JA, Hanney WJ. Platelet-Rich Plasma: Basic Science and Biological Effects. Strength Cond J 2018. [DOI: 10.1519/ssc.0000000000000402] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Gellhorn AC, Han A. The Use of Dehydrated Human Amnion/Chorion Membrane Allograft Injection for the Treatment of Tendinopathy or Arthritis: A Case Series Involving 40 Patients. PM R 2017; 9:1236-1243. [PMID: 28483683 DOI: 10.1016/j.pmrj.2017.04.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/29/2017] [Accepted: 04/15/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Degenerative joint and tendon injuries remain difficult to treat, with few effective conservative treatment options available. Regenerative approaches aim to promote the inherent healing capacity of injured tissues. Micronized dehydrated human amnion/chorion membrane (dHACM) injection is an emerging regenerative option with promising preclinical results. OBJECTIVE To test the clinical effectiveness of dHACM injection in patients with chronic tendinopathy and arthropathy. DESIGN Case series. SETTING Academic medical center outpatient sports medicine clinic. PATIENTS A total of 40 patients with chronic tendinosis or arthropathy who received dHACM over a period of 9 months. METHODS A structured interview was administered to patients by telephone to supplement the clinical information available in the medical chart. All patients received an ultrasound-guided injection of dHACM. MAIN OUTCOME MEASURES The primary outcome was change in pain level, and the secondary outcome was change in activities of daily living (ADLs) and sports/recreation function. More than 30% improvement in average pain and function was considered a successful outcome. RESULTS Patient pain and function were measured at 1, 2, and 3 months after the procedure. Patient-reported average pain scores decreased from a baseline value of 6.4 (95% confidence interval [CI] = 5.7-7.0) to 2.7 (95% CI = 2.1-3.3; P < .001) at 1 month, 1.7 (95% CI = 1.1-2.2; P < .001) at 2 months, and 1.4 (95% CI = 0.9-1.9; P < .001) at 3 months. The percentage of patients achieving clinical success, defined as 30% or greater improvement in pain levels, was 68% at 1 month, 82% at 2 months, and 91% at 3 months. Patient-reported functional impairment in ADLs decreased from 6.8 (95% CI = 6.0-7.5) to 2.0 (95% CI = 1.4-2.7) (P < .001); impairment in sports/recreation decreased from 8.5 (95% CI = 7.9-9.1) to 3.2 (95% CI = 2.6-3.9) (P < .001). Frequency of pain medication use decreased from 29 of 40 patients (72.5%) before the procedure to 9 of 40 patients (22.5%) at final follow up (P < .001). Localized pain at the injection site was common, but no other adverse events or side effects were reported. CONCLUSION In the setting of tendinosis or arthropathy, dHACM injection was clinically effective in reducing pain and improving function in a majority of adults. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Alfred C Gellhorn
- Division of Rehabilitation Medicine, Weill Cornell Medical College, 525 E. 68 Street, B16, New York, NY 10065(∗).
| | - Alex Han
- Warren Alpert Medical School at Brown University, Providence RI(†)
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