The clinical impact of platelet-rich plasma on tendinopathy compared to placebo or dry needling injections: A meta-analysis

Therapeutic Effects of Dry Needling on Lateral Epicondylitis: An Updated Systematic Review and Meta-analysis

OBJECTIVE

To investigate the therapeutic effects of dry needling on lateral epicondylitis and identify a relatively more effective needling technique.

DATA SOURCES

English databases (Pubmed, Web of Science, Scopus, EBSCO, ScienceDirect, Taylor & Francis, ProQuest, Cochrane, Ovid, and Embase) and Chinese databases (China National Knowledge Infrastructure, Wanfang, and VIP) were searched.

STUDY SELECTION

This study included randomized controlled trials for comparing the effectiveness of dry needling with other treatment methods for lateral epicondylitis. The primary outcome measures were pain intensity and elbow disability, while the secondary outcome measures included grip strength and upper limb function.

DATA EXTRACTION

Data extraction was performed by 2 researchers who used the Cochrane risk of bias analysis tool and the Physiotherapy Evidence Database checklist to assess the risk of bias and methodological quality of the included studies. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to assess the quality of evidence.

DATA SYNTHESIS

A total of 17 studies that involved 979 subjects were included in this research. Dry needling exhibited a significant advantage in improving pain intensity among patients with lateral epicondylitis within 1 week after treatment (mean difference [MD]=-0.95, 95% confidence interval [CI], -1.88 to -0.02). Within 1 week and in the follow-ups that exceeded 1 week, dry needling also demonstrated better improvement in elbow disability (<1 week: standardized mean difference [SMD]=-1.37, 95% CI, -1.88 to -0.86; ≥1 week: SMD=-1.32, 95% CI, -2.23 to -0.4) and grip strength (<1 week: SMD=0.27, 95% CI, 0.01 to 0.53; ≥1 week: SMD=0.45, 95% CI, 0.02 to 0.88). Trigger point dry needling with local twitch response exhibited more significant improvement in pain intensity within 1 week (MD=-1.09, 95% CI, -1.75 to -0.44).

CONCLUSIONS

Dry needling demonstrates good therapeutic effects on pain intensity (within 1 week), function, and grip strength among patients with lateral epicondylitis. Local twitch response is necessary in treatment that targets trigger points.

Role of platelet-rich plasma in the treatment of rotator cuff tendinopathy

Shoulder pain is a common musculoskeletal complaint, and rotator cuff (RC) pathologies are one of the main causes. The RC undergoes various tendinopathic and avascular changes during the aging process. Other degenerative changes affecting its healing potential make it an appealing target for biological agents. Platelet-rich plasma (PRP) has demonstrated the potential to deliver a high concentration of several growth factors and anti-inflammatory mediators, and its clinical use is mainly supported by experiments that demonstrated its positive effect on muscle, ligaments, and tendinous cells. This review aimed to specify the role of PRP and its future applications in RC tendinopathies based on the current clinical evidence. Due to the different characteristics and conflicting outcomes, clinicians should use PRP with moderate expectations until more consistent evidence is available. However, it is reasonable to consider PRP in patients with contraindications to corticosteroid injections or those with risk factors for inadequate healing. Its autologous origin makes it a safe treatment, and its characteristics make it a promising option for treating RC tendinopathy, but the efficacy has yet to be established.

Local Corticosteroid Injection Versus Dry Needling in the Treatment of Lateral Epicondylitis

Background Lateral epicondylitis (LE) is an inflammation or micro-tearing of the tendons that join the forearm muscles on the lateral aspect of the elbow. Primary treatment of LE includes rest from offending activity and corticosteroid therapy for pain control. Dry needling (DN) is a relatively new therapy for LE. This study examined the results of DN therapy with corticosteroid injection. We aimed to compare pain relief and improvements in functional disability of LE patients treated via DN and corticosteroid injection in a tertiary care center. Methodology A prospective randomized control study was conducted among 54 patients in the Orthopaedics Department of R L Jalappa Hospital from January 2022 to May 2022. Patients received either DN or injectable corticosteroid therapy, and treatment groups were randomized using single-blinded randomization with sealed envelopes. Patients were evaluated using the Patient-Related Tennis Elbow Evaluation (PRTEE) score before the intervention and four and eight weeks after the intervention. Results A total of 54 patients were included in the final analysis. The mean age in the DN group was 43.96 ± 8.15 years and 44.74 ± 8.33 years in the corticosteroid group. In the DN group, 17 (62.96%) patients were male, and in the corticosteroid group, 16 (59.26%) patients were male. The differences in the PRTEE score at the fourth and eighth-week follow-up with baseline value (pre-injection) were statistically significant (p < 0.001). Conclusions DN is a low-cost, minimally invasive, and low-risk therapy whereas corticosteroid therapy is costly and produces systemic side effects in the long term. In this study, during the last follow-up visit, the PRTEE score improved in the DN group compared to the corticosteroid group.

Diagnosing, Managing, and Supporting Return to Work of Adults With Rotator Cuff Disorders: A Clinical Practice Guideline

OBJECTIVE: To develop a clinical practice guideline covering the assessment, management, and return to work of adults with rotator cuff disorders. DESIGN: Clinical practice guideline. METHODS: Using systematic reviews, appraisal of the literature, and an iterative approach to obtain consensus from key stakeholders, clinical recommendations and algorithms were developed in the context of the health care system and work environment of the province of Quebec (Canada). RESULTS: Recommendations (n = 73) and clinical decision algorithms (n = 3) were developed to match the objectives. The initial assessment should include the patient's history, a subjective assessment, and a physical examination. Diagnostic imaging is only necessary in select circumstances. Acetaminophen, nonsteroidal anti-inflammatory drugs, and injection therapies may be useful to reduce pain in the short term. Clinicians should prescribe an active and task-oriented rehabilitation program (exercises and education) to reduce pain and disability in adults with rotator cuff disorders. Subacromial decompression is not recommended to treat rotator cuff tendinopathy. Surgery is appropriate for selected patients with a full-thickness rotator cuff tear. A return-to-work plan should be developed early, in collaboration with the worker and other stakeholders, and must combine multiple strategies to promote return to work. CONCLUSION: This clinical practice guideline was developed to assist the multidisciplinary team of clinicians who provide health care for adults with a rotator cuff disorder. The CPG guides clinical decisionmaking for diagnosis and treatment, and planning for successful return to work. J Orthop Sports Phys Ther 2022;52(10):647-664. Epub: 27 July 2022. doi:10.2519/jospt.2022.11306.

Comparison of the efficacy of corticosteroid, dry needling, and PRP application in lateral epicondylitis

PURPOSE

The aim of this study was to compare the short-term efficacy of dry needling, corticosteroids, and platelet-rich plasma application (PRP) in the management of lateral epicondylitis.

METHODS

The study included 72 patients diagnosed with lateral epicondylitis divided into three groups of 24 individuals using the sealed envelope method. Group 1 underwent dry needling, Group 2 received 40 mg methylprednisolone acetate, and Group 3 received PRP treatment. Patients were assessed using the visual analog scale (VAS) and the Disabilities of the Shoulder, Arm, and Hand (DASH) score, and Jamar grip strength before treatment and 3rd week and 3rd month.

RESULTS

At the 3rd month, the mean VAS score was 1.16 ± 0.56 in dry needling group and 0.75 ± 0.60 in corticosteroids group, showing a statistically significant difference between dry needling and corticosteroids group, and between corticosteroids and PRP group (p = 0.015 and p = 0.000, respectively). At the 3rd week and 3rd month, VAS scores decreased in each treatment modality group, showing a statistically significant difference between the groups (p < 0.01). Jamar grip strength increased over time in all groups. There were no significant differences between the DASH scores of all groups at the 3rd week (p > 0.05). DASH scores decreased significantly from the 3rd week to the 3rd month in dry needling and corticosteroids group (p < 0.01), while it increased slightly in PRP group during the same period with a statistically insignificant change (p > 0.05). DASH scores decreased significantly at the 3rd month for all groups (p = 0.014).

CONCLUSION

Dry needling is an effective and safe application for the short-term treatment of lateral epicondylitis.

Mesenchymal Stem Cells Use in the Treatment of Tendon Disorders: A Systematic Review and Meta-Analysis of Prospective Clinical Studies

Objective

To evaluate the efficacy and safety of mesenchymal stem cells (MSCs) therapy in patients with tendon disorders enrolled in prospective clinical studies.

Methods

We systematically searched prospective clinical studies that investigated the effects of MSC administration on human tendon disorders with at least a 6-month follow-up period in the PubMed-MEDLINE, EMBASE, and Cochrane Library databases. The primary outcome of interest was the change in pain on motion related to tendon disorders. Meta-regression analyses were performed to assess the relationship between MSC dose and pooled effect sizes in each cell dose.

Results

Four prospective clinical trials that investigated the effect of MSCs on tendon disorders were retrieved. MSCs showed a significant pooled effect size (overall Hedges’ g pooled standardized mean difference=1.868; 95% confidence interval, 1.274–2.462; p<0.001). The treatment with MSCs improved all the aspects analyzed, namely pain, functional scores, radiological parameters (magnetic resonance image or ultrasonography), and arthroscopic findings. In the meta-regression analysis, a significant cell dose-dependent response in pain relief (Q=9.06, p=0.029) was observed.

Conclusion

Our meta-analysis revealed that MSC therapy may improve pain, function, radiological, and arthroscopic parameters in patients with tendon disorders. A strong need for large-scale randomized controlled trials has emerged to confirm the long-term functional improvement and adverse effects of MSC therapies in tendon disorders.

Dry Needling of a Healthy Rat Achilles Tendon Increases Its Gene Expressions: A Pilot Study

BACKGROUND

Tendon dry needling is a potential treatment for tendinopathies. Several hypotheses have been proposed to explain its underlying mechanisms. No studies (to the best of our knowledge) have investigated changes in gene expression.

OBJECTIVE

To investigate histological and gene expression changes after the application of dry needling to the healthy Achilles tendons of rats.

METHODS

Six Sprague-Dawley male rats were randomly divided into two groups: no intervention or dry needling. Dry needling consisted of three sessions (once per week) to the Achilles tendon. Molecular expression of several genes involved in tendon repair and remodeling (e.g., Cox2, Mmp2, Mmp9, Col1a1, Col3a1, Vefg, and Scx) was assessed 7 days after the last needling session (day 28) or 28 days after for the no-intervention group. Histological tissue changes were determined with hematoxylin-eosin analyses.

RESULTS

The hematoxylin-eosin-stained images revealed no substantial differences in collagen structure or the presence of inflammatory cells between the dry needling and no-intervention groups. A significant increase in the molecular expression of Cox2, Mmp2, Col3a1, and Scx genes was observed in Achilles tendons treated with dry needling when compared with the no-intervention group.

CONCLUSION

This animal pilot study found that the application of dry needling to the healthy Achilles tendons of rats is able to increase the expression of genes associated with collagen regeneration and tissue remodeling of the extracellular matrix with no further histological damage to the tendon.

Functional and Pain Improvement in Tennis Elbow with Dry Needling as Alternative Treatment: Case Series

Collapse

The Effectiveness of Minimally Invasive Techniques in the Treatment of Patellar Tendinopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The aim was to determine the effectiveness of minimally invasive techniques (MIT) in patients with patellar tendinopathy. Database searches were performed for randomized controlled trials (RCTs) in electronic databases (WOS, Cochrane Central, SportDiscus, and Medline via PubMed and PEDro). The inclusion criteria used were published in English or Spanish and involving adults with patellar tendinopathy (pain on the inferior pole of the patella for a minimum of 3 months), with at least one group receiving MIT. The quality of the relevant RCTs was evaluated using the PEDro scale. The primary outcome was functionality using the VISA-p questionnaire. Secondary outcome was focused on pain. A total of 1164 studies were screened for possible inclusion in our systematic review. Finally, 10 RCTs were included with a total of 326 individuals. Five RCTs were included in the meta-analysis. The quality assessment revealed that all the studies included were considered to possess high methodological quality. All studies analyzing MIT such as platelet-rich plasma (PRP), dry needling, or skin-derived tenocyte-like cells, when combined with exercise, proved to be effective for patellar tendinopathy. Moreover, the PRP technique with doses greater than 4 mL together and combined with an exercise program lasting over 6 weeks obtained better results in functionality and pain than other treatments in the short term. However, in the long term, dry needling and skin-derived tenocyte-like cells are more effective than PRP. Although the infiltration of drugs was effective at posttreatment, these improvements were not maintained over time and may have secondary effects. Although there are no RCTs analyzing the effectiveness of MIT like percutaneous needle electrolysis, there has been an increasing number of publications achieving excellent results in the last years. However, it is necessary to develop RCTs analyzing not only the effect but also comparing the effectiveness between different MIT such as dry needling and percutaneous needle electrolysis.

Clinical management of tendinopathy: A systematic review of systematic reviews evaluating the effectiveness of tendinopathy treatments

While the pathoetiology is disputed, a wide array of treatments is available to treat tendinopathy. The most common treatments found in the literature include therapeutic modalities, exercise protocols, and surgical interventions; however, their effectiveness remains ambiguous. The purpose of this study was to perform a systematic review of systematic reviews to determine the ability of therapeutic interventions to improve pain and dysfunction in patients with tendinopathy regardless of type or location. Five databases were searched for systematic reviews containing only randomized control trials to determine the effectiveness of treatments for tendinopathies based on pain and patient-reported outcomes. Systematic reviews were assessed via the Assessment of Multiple Systematic Reviews (AMSTAR) for methodological quality. From the database search, 3,295 articles were found, 107 passed the initial inclusion criteria. After further review, 25 systematic reviews were included in the final qualitative analysis. The AMSTAR scores were relatively high (8.8 ± 1.0) across the 25 systematic reviews. Eccentric exercises were the most common and consistently effective treatment for tendinopathy across systematic reviews. Low-level laser therapy and extracorporeal shockwave therapy demonstrated moderate effectiveness, while platelet-rich plasma injections demonstrated inconclusive evidence on their ability to decrease tendinopathy-related pain and improve function. Corticosteroids also showed some effectiveness for short-term pain, but for the long-term use deemed ineffective and at times contraindicated. Regarding surgical options, minimally invasive procedures were more effective compared to open surgical interventions. When treating tendinopathy regardless of location, eccentric exercises were the best treatment option to improve tendinopathy-related pain and improve self-reported function.

A critical overview of the current myofascial pain literature - January 2020

We are starting 2020 with 6 basic research studies, 9 review articles, 14 dry needling/injection studies, and one manual therapy paper for a total of 30 new papers. Topics range from studies on mechanisms, inflammatory mediators in myofascial pain, fascia, screening, Platelet-rich plasma intramuscular injections, and temporal summation to clinical studies on patients with tension-type headache, chronic pelvic pain, knee osteoarthritis, plantar fasciitis, generalized musculoskeletal pain, neck pain, breast cancer, tendinopathies, thoracic outlet syndrome, and canine dry needling, among others.

Shoulder Rotator Cuff Disorders: A Systematic Review of Clinical Practice Guidelines and Semantic Analyses of Recommendations

OBJECTIVES

To perform a systematic review of clinical practice guidelines (CPGs) and semantic analysis of specific clinical recommendations for the management of rotator cuff disorders in adults.

DATA SOURCES

A systematic bibliographic search was conducted up until May 2018 in Medline, Embase, and Physiotherapy Evidence Database, or PEDro, databases, in addition to 12 clinical guidelines search engines listed on the Appraisal of Guidelines for Research and Evaluation (AGREE) website.

STUDY SELECTION

Nine CPGs on the management of rotator cuff disorders in adults or workers, available in English or French, and published from January 2008 onward, were included and screened by 2 independent reviewers.

DATA EXTRACTION

CPG methodology was assessed with the AGREE II checklist. A semantic analysis was performed to compare the strength of similar recommendations based on their formulation. The recommendations were categorized in a standardized manner considering the following 4 levels: "essential," "recommended," "may be recommended," and "not recommended."

DATA SYNTHESIS

Methodological quality was considered high for 3 CPGs and low for 6. All CPGs recommended active treatment modalities, such as an exercise program in the management of rotator cuff disorders. Acetaminophen or nonsteroidal anti-inflammatory drug prescriptions and corticosteroid injections were presented as modalities that may be recommended to decrease pain. Recommendations related to medical imagery and surgical opinion varied among the guidelines. The most commonly recommended return-to-work strategies included intervening early, use of a multidisciplinary approach, and adaptation of work organization.

CONCLUSIONS

Only 3 CPGs were of high quality. The development of more rigorous CPGs is warranted.

Dry Needling as a Treatment Modality for Tendinopathy: a Narrative Review

PURPOSE OF REVIEW

Tendinopathy describes a combination of pain, swelling, and impaired performance of the tendon and around structures. There are various treatment options for tendinopathy with unclear efficacy. Dry needling involves inserting needles into the affected tendon, and it is thought to disrupt the chronic degenerative process and encourage localized bleeding and fibroblastic proliferation. The purpose of this review is to review the use of dry needling as a treatment modality for tendinopathy.

RECENT FINDINGS

The effectiveness of dry needling for treatment of tendinopathy has been evaluated in 3 systematic reviews, 7 randomized controlled trials, and 6 cohort studies. The following sites were studied: wrist common extensor origin, patellar tendon, rotator cuff, and tendons around the greater trochanter. There is considerable heterogeneity of the needling techniques, and the studies were inconsistent about the therapy used after the procedure. Most systematic reviews and randomized controlled trials support the effectiveness of tendon needling. There was a statistically significant improvement in the patient-reported symptoms in most studies. Some studies reported an objective improvement assessed by ultrasound. Two studies reported complications. Current research provides initial support for the efficacy of dry needling for tendinopathy treatment. It seems that tendon needling is minimally invasive, safe, and inexpensive, carries a low risk, and represents a promising area of future research. In further high-quality studies, tendon dry needling should be used as an active intervention and compared with appropriate sham interventions. Studies that compare the different protocols of tendon dry needling are also needed.

Effect of platelet-rich plasma on the degenerative rotator cuff tendinopathy according to the compositions

Background

There are controversies about platelet-rich plasma (PRP) as an established treatment option for rotator cuff (RC) tendinopathy. The purpose of the study was to find the relation of cellular component with clinical efficacy in RC tendinopathy and to find the composition of PRP in treating RC tendinopathy.

Methods

A total 30 patients were recruited and divided into PRP and control groups. In the PRP group, 2 ml of PRP solution was injected to the hypoechoic lesion of degenerative supraspinatus via 22-gauge syringe with peppering technique. Patients in the control group were taught rotator cuff strengthening exercises. American Shoulder and Elbow Surgeons (ASES), Constant-Murley score, and numeric rating scale (NRS) were measured before, 6 weeks after, 12 weeks after, and 24 weeks after the procedure. PRP compositions were analyzed using the 1 ml of PRP solution.

Results

Linear regression analysis showed no significant difference of ASES and Constant-Murley scores between the groups at 6 weeks (P = 0.582 and 0.258) and at 12 weeks (P = 0.969 and 0.795) but showed a significant difference at 24 weeks (P = 0.050 and 0.048). Independent t test showed significant group difference of NRS at 6 weeks (P = 0.031) but not at 12 and 24 weeks (P = 0.147 and 0.935). 5.19 pg/ml in IL-1β and 61.79 μg/ml in TGF-β1 were acquired as cutoff values to predict meaningful improvement. The PRP subgroup above IL-1β or TGF-β1 cutoff value showed significant differences in all clinical outcomes compared with the exercise group while the PRP subgroup below the cutoff value showed no significant differences in linear regression analysis.

Conclusions

Our study can help to find the optimal PRP condition and to enhance the effect of PRP on RC tendinopathy.

Trial registration

All the patients were registered in our Institutional Ethics Committee (approval number 2014-05-009).

Efficacy of platelet-rich plasma for non-transfusion use: Overview of systematic reviews

INTRODUCTION

Platelet-rich plasma (PRP) is a blood component therapy with a supraphysiological concentration of platelets derived from allogenic or, more commonly, autologous blood. PRP has been used in different non-transfusion indications because of its role in the promotion of tissue repair and healing, in fields such as Traumatology, Dermatology and Dentistry.

OBJECTIVE

To provide a synthesis of the efficacy of PRP for different clinical situations.

METHODS

Systematic searches were carried out in MEDLINE, Embase, Cochrane Library and LILACS in July 2018 to identify systematic reviews (SRs) of randomized clinical trials (RCTs) focusing on PRP for non-transfusion use. Two authors independently screened all retrieved references in two stages (titles and abstracts at a first stage and full texts at a second stage). The methodological quality of SRs that met the eligibility criteria was appraised by AMSTAR 2. Conclusions were based on the most recent SRs with highest quality.

RESULTS

One thousand two hundred and forty references were retrieved. After checking the inclusion criteria, 29 SRs of RCTs related to three different fields (wound care, Orthopedics and Dentistry) were included. The results suggest the benefit of PRP for different clinical situations, such as diabetic wounds, acute lesions of musculoskeletal system, rotator cuff lesions, tendinopathies, knee and hip osteoarthritis, total knee arthroplasty, allogenic bone graft for dental implants and periodontal intrabony defects.

CONCLUSION

There is low to moderate quality evidence supporting the efficacy of PRP for specific clinical situations. The low quality of the evidence limits the certainty of these findings. Well-planned and well-conducted RCTs are still needed to further assess the efficacy of PRP.

Ultrasound-Guided Interventions in Lateral Epicondylitis

Lateral epicondylitis is a painful condition related to the myotendinous origin of the extensor muscles at the lateral epicondyle of the humerus. Primary treatment typically involves the use of rest, non-steroidal anti-inflammatory drugs (NSAIDs), and physiotherapy. However, in refractory cases where conventional therapy is ineffective, ultrasound-guided injection therapies have become a growing form of treatment. These include needle tenotomy, autologous whole blood injection (AWB), platelet-rich plasma (PRP) injection and steroid injection. The consensus regarding the efficacy of individual approaches of ultrasound-guided treatment is unclear in the literature, and is explored further in this review.When evaluating these injection therapies individually, there are multiple case series describing the efficacy of each intervention in refractory lateral epicondylitis. A systematic review of needle tenotomy demonstrates an improvement in pain symptoms for patients with this condition, but all studies were poorly designed with no placebo or control group. Additionally, for PRP therapy, a systematic review performed in 2013 demonstrated a statistically significant improvement in pain and functionality for refractory lateral epicondylitis. However, these studies were similarly associated with a high risk of bias. Autologous whole blood injection has been evaluated through well-designed studies to show statistically significant reductions in pain with this intervention. But very few studies in total have been completed using AWB for lateral epicondylitis, and therefore no clear conclusions can be drawn at this time. Finally, corticosteroid use overall is unsupported in the evidence both in the short and long term, especially given that this condition is not an inflammatory pathology.

Platelet-rich plasma versus lidocaine as tenotomy adjuvants in people with elbow epicondylopathy: a randomized controlled trial

OBJECTIVES

To determine the efficacy of platelet-rich plasma (PRP) compared to lidocaine as a tenotomy adjuvant for people with elbow tendinopathy.

METHODS

Our study was a parallel-group, double-blind, randomized trial involving 71 patients with recalcitrant elbow tendinopathy who received two sessions of ultrasound-guided tenotomy with either PRP or lidocaine in a tertiary public hospital. The primary end point was the percentage of patients with an improvement exceeding 25% reduction in disability (Spanish version of the Disabilities of the Arm, Shoulder and Hand questionnaires-DASH-E) at 6 and 12 months; the secondary outcome was the percentage of patients exceeding 25% reduction in pain (VAS-P).

RESULTS

There was no evidence of significant differences in the proportion of patients who experienced clinically relevant improvements. After 6 months, 18 patients (78.59%) in the lidocaine group and 19 patients (73.08%) in the PRP group showed improved function above 25% (unadjusted odds ratio, 0.90; 95% confidence interval [CI], 0.90 (0.17 to 4.60)); 21 patients (72.21%) in the lidocaine group versus 22 patients (84.62%) in the PRP group achieved more than 25% pain reduction (unadjusted odds ratio, 0.48; 95% CI, 0.10 to 2.37). After 12 months, 17 patients (70.83%) in the lidocaine group versus 19 patients (76%) in the PRP group had improved function (unadjusted odds ratio, 0.71; 95% CI, 0.13 to 3.84), and 19 patients (76%) in the lidocaine group versus 20 patients (90.91%) in the PRP group had improved pain above 25% (unadjusted odds ratio, 0.35; 95% CI, 0.06 to 2.51). Hypercholesterolemia and baseline vascularization influenced outcomes. There were no differences between groups in the adjusted odds ratios.

CONCLUSION

PRP results in similar improvements to those obtained with lidocaine. Selecting patients according to their pretreatment status can improve treatment efficacy.

TRIAL REGISTRATION

NCT01945528 , EudraCT 2013-000478-32. Registered 18 August 2013, enrolment of the first participant 10 March 2014.

An injectable platelet lysate-hyaluronic acid hydrogel supports cellular activities and induces chondrogenesis of encapsulated mesenchymal stem cells

Developing scaffolds that can provide cells and biological cues simultaneously in the defect site is of interest in tissue engineering field. In this study, platelet lysate (PL) as an autologous and inexpensive source of growth factors was incorporated into a cell-laden injectable hyaluronic acid-tyramine (HA-TA) hydrogel. Subsequently, the effect of platelet lysate on cell attachment, viability and differentiation of human mesenchymal stem cell (hMSCs) toward chondrocytes was investigated. HA-TA conjugates having a degree of substitution of 20 TA moieties per 100 disaccharide units were prepared and crosslinked in the presence of horseradish peroxidase and low concentrations of hydrogen peroxide. The storage moduli of the gels ranged from 500 to 2000 Pa and increased with increasing polymer concentration. In contrast to a retained round shape of the cells when using pure HA-TA hydrogel, the hMSCs attached and spread out in PL enriched matrix. The enrichment of hMSCs laden HA-TA hydrogels with PL induced a cartilage like extra cellular matrix deposition in vitro. The hMSCs increasingly deposited collagen type II and proteoglycans over time. The deposition of the new extracellular matrix (ECM) is simultaneous with gel degradation and resulted ultimately in the formation of a tough dense matrix. These findings demonstrate the potential of injectable HA-TA-PL hydrogel as a cell delivery system for cartilage regeneration. STATEMENT OF SIGNIFICANCE: Cartilage tissue has limited ability to self-repair because of its avascular nature. To have an efficient cartilage tissue regeneration, we combined platelet lysate (PL), as an autologous and inexpensive source of growth factors, with an injectable hyaluronic acid tyramine (HA-TA) hydrogel scaffold. Platelet lysate had a vital role in supporting human mesenchymal stem cells (hMSCs) activities, like cell attachment, viability and proliferation in the 3D hydrogel structure. Also, the hMSCs encapsulated HA-TA induced hyaline cartilage generation when placed in chondrogenic differentiation medium. This study introduces a new system for cartilage tissue engineering, which can be injected in a minimally invasive manner and is rich with patient's own growth factors and biological cues.

Blood Plasma Derivatives for Tissue Engineering and Regenerative Medicine Therapies

Platelet-rich plasma (PRP) and its derivatives have been investigated and applied in regenerative medicine. The use of PRP as a supplement of cell culture media has consistently shown to potentiate stem cell proliferation, migration, and differentiation. In addition, the clinical utility of PRP is supported by evidence that PRP contains high concentrations of growth factors (GFs) and proteins which contribute to the regenerative process. PRP based therapies are cost effective and also benefit from the accessibility and safety of using the patient's own GFs. In the last years, a great development has been witnessed on PRP based biomaterials, with both structural and functional purposes. In this study we overview the most relevant PRP applications encompassing PRP based materials for tissue engineering and regenerative medicine. This review also summarizes the challenges in the fields of tissue engineering and regenerative medicine and provides a perspective on future directions.

Efficacy of platelet-rich plasma as conservative treatment in orthopaedics: a systematic review and meta-analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to evaluate the benefit of platelet-rich plasma (PRP) in non-surgical orthopaedic procedures.

MATERIAL AND METHODS

We searched the Cochrane Wounds Specialized Register, CENTRAL, MEDLINE (through PUBMED), Embase, and SCOPUS. We also searched clinical trials registries for ongoing and unpublished studies and checked reference lists to identify additional studies.

RESULTS

We found 36 randomised controlled trials (2,073 patients) that met our inclusion criteria. The included studies mostly had small numbers of participants (from 20 to 225). Twenty-eight studies included patients with lateral epicondylitis or plantar fasciitis. PRP was compared to local steroids injection (19 studies), saline injection (6 studies), autologous whole blood (4 studies), local anaesthetic injection (3 studies), dry needling injection (3 studies), and to other comparators (4 studies). Primary outcomes were pain and function scores, and adverse events. On average, it is unclear whether or not use of PRP compared to controls reduces pain scores and functional score at short- (up to 3 months) and medium- (4-6 months) term follow-up. The available evidence for all the comparisons was rated as very low quality due to inconsistency, imprecision, and risk of bias in most of the selected studies. There were no serious adverse events related to PRP injection or control treatments.

CONCLUSIONS

The results of this meta-analysis, which documents the very marginal effectiveness of PRP compared to controls, does not support the use of PRP as conservative treatment in orthopaedics.

Comparative Effectiveness of Injection Therapies in Rotator Cuff Tendinopathy: A Systematic Review, Pairwise and Network Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To compare the effectiveness of diverse injections in patients with rotator cuff tendinopathy using pairwise and network meta-analysis.

DATA SOURCES

PubMed, EMBASE, Scopus, and Cochrane Library were searched for studies published up to September 31, 2017.

STUDY SELECTION

We included all published or unpublished randomized controlled trials (RCTs) comparing diverse injections including corticosteroid, nonsteroidal anti-inflammatory drugs, hyaluronic acid, botulinum toxin, platelet-rich plasma (PRP), and prolotherapy in patients with rotator cuff tendinopathy. Among the 1495 records screened, 18 studies were included in the meta-analysis.

DATA EXTRACTION

The quality of RCTs was assessed with Cochrane Risk of Bias Tool by 2 independent raters. The primary outcome was pain reduction, and the secondary outcome was functional improvement.

DATA SYNTHESIS

Standardized mean difference (SMD) was used for pairwise and network meta-analysis. In pairwise meta-analysis, corticosteroid was more effective only in the short term in both pain reduction and functional improvement. Network meta-analysis indicated that prolotherapy significantly reduced pain compared with placebo in the long term (over 24wk; SMD: 2.63; 95% confidence interval [CI], 1.88-3.38); meanwhile PRP significantly improved shoulder function compared with placebo in the long term (over 24wk; SMD: 0.44; 95% CI, 0.05-0.84).

CONCLUSIONS

For patients with rotator cuff tendinopathy, corticosteroid plays a role in the short term (3-6wk) but not in long-term (over 24wk) pain reduction and functional improvement. By contrast, PRP and prolotherapy may yield better outcomes in the long term (over 24wk). On account of heterogeneity, interpreting these results with caution is warranted.

How far have biological therapies come in regenerative sports medicine?

INTRODUCTION

Regular engagement in sports produces many health benefits, but also exposes to increased injury risk. The quality of medical care available is crucial not only for sports trauma but also to avoid overuse syndromes and post-traumatic degenerative conditions.

AREAS COVERED

We provide background information on some clinical needs in sport injuries and describe the main families of biological products used in clinical practice. We also discuss limitations of the current clinical experience.

EXPERT OPINION

Sport and exercise impairment affects different segments of the population with different needs. The exceptional demands of elite athletes and subsequent media coverage have created hype around regenerative therapies. Statistical evidence, whether weak (cell products) or moderate (PRPs), is not enough to drive medical decisions because of the heterogeneity of the biological products available and their application procedures. Moreover, the specific needs of the different segments of the population along with the available clinical evidence for each musculoskeletal condition should be considered in the decision-making process. There is urgent need to develop regenerative protocols combined with post-intervention rehabilitation, and gather meaningful clinical data on the safety and efficacy of these interventions in the different populations segments.

Pathogenesis and Management of Tendinopathies in Sports Medicine

Objective

Tendinopathy is a major clinical problem in sports medicine and is often difficult to treat. Traditional therapeutic approaches have focused on reducing inflammation, yet research suggests that little to no inflammation is present in the tendons that fail to heal. The purpose of this review was to evaluate the effectiveness of the available treatment options for tendinopathy and to inform best clinical practices.

Design

A narrative review.

Methods

A comprehensive search of electronic databases (PubMed, Google Scholar and Web of Science) was conducted to identify relevant studies through June 2016. Studies were deemed relevant if they were published in English and contained original research on the management of tendinopathy in humans.

Results

Studies varied in methodological quality and were often limited by small sample size and lack of sufficient control groups. Critical evaluation of the literature suggests that physical therapy with or without eccentric exercise should be considered a first-line treatment. Corticosteroids and nonsteroidal anti-inflammatory drugs provide short-term symptomatic relief, but long-term efficacy has not been demonstrated. Inconsistent results do not support the routine use of prolotherapy, platelet-rich plasma injections and topical nitric oxide patches. Operative intervention should be reserved until conservative measures fail or an obvious operative lesion is present.

Conclusions

While numerous therapeutic modalities exist for tendinopathy in the athlete, the ideal treatment protocol has not been clearly defined. The development of new targeted therapies for tendinopathy is likely to follow a greater understanding of the cellular and molecular mechanisms that underlie its pathogenesis.

No evidence for the use of stem cell therapy for tendon disorders: a systematic review

INTRODUCTION

Stem cells have emerged as a new treatment option for tendon disorders. We systematically reviewed the current evidence for stem cell therapy in tendon disorders.

METHODS

Randomised and non-randomised controlled trials, cohort studies and case series with a minimum of 5 cases were searched in MEDLINE, CENTRAL, EMBASE, CINAHL, PEDro and SPORTDiscus. In addition, we searched grey literature databases and trial registers. Only human studies were included and no time or language restrictions were applied to our search. All references of included trials were checked for possibly eligible trials. Risk of bias assessment was performed using the Cochrane risk of bias tool for controlled trials and the Newcastle-Ottawa scale for case series. Levels of evidence were assigned according to the Oxford levels of evidence.

RESULTS

4 published and three unpublished/pending trials were found with a total of 79 patients. No unpublished data were available. Two trials evaluated bone marrow-derived stem cells in rotator cuff repair surgery and found lower retear rates compared with historical controls or the literature. One trial used allogenic adipose-derived stem cells to treat lateral epicondylar tendinopathy. Improved Mayo Elbow Performance Index, Visual Analogue Pain scale and ultrasound findings after 1-year follow-up compared with baseline were found. Bone marrow-derived stem cell-treated patellar tendinopathy showed improved International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score subscales and Tegner scores after 5-year follow-up. One trial reported adverse events and found them to be mild (eg, swelling, effusion). All trials were at high risk of bias and only level 4 evidence was available.

CONCLUSIONS

No evidence (level 4) was found for the therapeutic use of stem cells for tendon disorders. The use of stem cell therapy for tendon disorders in clinical practice is currently not advised.

Optimisation of platelet concentrates therapy: Composition, localisation, and duration of action

Platelet concentrates (PC) generally refers to a group of products that are prepared from autologous blood intended to enhance healing activities. PC therapy is now very popular in treating musculoskeletal injuries; however, inconsistent clinical results urge the need to understand the working mechanism of PC. It is generally believed that the platelet-derived bioactive factors are the active constituents, and their bioavailability in the vicinity of the lesion sites determines the treatment efficacies. Therefore, the composition, localisation, and duration of the action of PC would be key determinants. In this review, we discuss how different preparations and delivery methods of PC would affect the treatment outcomes with respect to clinical evidence about PC therapy for osteoarthritis, tendinopathies, rotator cuff tears, anterior cruciate ligament injuries, and bone fractures. This review can be used as a quick guide for the use of PC therapy and provide insights for the further optimisation of the therapy in the near future.