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D'Souza RS, Her YF, Hussain N, Karri J, Schatman ME, Calodney AK, Lam C, Buchheit T, Boettcher BJ, Chang Chien GC, Pritzlaff SG, Centeno C, Shapiro SA, Klasova J, Grider JS, Hubbard R, Ege E, Johnson S, Epstein MH, Kubrova E, Ramadan ME, Moreira AM, Vardhan S, Eshraghi Y, Javed S, Abdullah NM, Christo PJ, Diwan S, Hassett LC, Sayed D, Deer TR. Evidence-Based Clinical Practice Guidelines on Regenerative Medicine Treatment for Chronic Pain: A Consensus Report from a Multispecialty Working Group. J Pain Res 2024; 17:2951-3001. [PMID: 39282657 PMCID: PMC11402349 DOI: 10.2147/jpr.s480559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 08/21/2024] [Indexed: 09/19/2024] Open
Abstract
Purpose Injectable biologics have not only been described and developed to treat dermal wounds, cardiovascular disease, and cancer, but have also been reported to treat chronic pain conditions. Despite emerging evidence supporting regenerative medicine therapy for pain, many aspects remain controversial. Methods The American Society of Pain and Neuroscience (ASPN) identified the educational need for an evidence-based guideline on regenerative medicine therapy for chronic pain. The executive board nominated experts spanning multiple specialties including anesthesiology, physical medicine and rehabilitation, and sports medicine based on expertise, publications, research, and clinical practice. A steering committee selected preliminary questions, which were reviewed and refined. Evidence was appraised using the United States Preventive Services Task Force (USPSTF) criteria for evidence level and degree of recommendation. Using a modified Delphi approach, consensus points were distributed to all collaborators and each collaborator voted on each point. If collaborators provided a decision of "disagree" or "abstain", they were invited to provide a rationale in a non-blinded fashion to the committee chair, who incorporated the respective comments and distributed revised versions to the committee until consensus was achieved. Results Sixteen questions were selected for guideline development. Questions that were addressed included type of injectable biologics and mechanism, evidence in treating chronic pain indications (eg, tendinopathy, muscular pathology, osteoarthritis, intervertebral disc disease, neuropathic pain), role in surgical augmentation, dosing, comparative efficacy between injectable biologics, peri-procedural practices to optimize therapeutic response and quality of injectate, federal regulations, and complications with mitigating strategies. Conclusion In well-selected individuals with certain chronic pain indications, use of injectable biologics may provide superior analgesia, functionality, and/or quality of life compared to conventional medical management or placebo. Future high-quality randomized clinical trials are warranted with implementation of minimum reporting standards, standardization of preparation protocols, investigation of dose-response associations, and comparative analysis between different injectable biologics.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yeng F Her
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Jay Karri
- Departments of Orthopedic Surgery and Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Christopher Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Thomas Buchheit
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Brennan J Boettcher
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | | | - Scott G Pritzlaff
- Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA, USA
| | | | - Shane A Shapiro
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Johana Klasova
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jay S Grider
- Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Ryan Hubbard
- Department of Sports Medicine, Anderson Orthopedic Clinic, Arlington, VA, USA
| | - Eliana Ege
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Shelby Johnson
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Max H Epstein
- Department of Physical Medicine & Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Eva Kubrova
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Mohamed Ehab Ramadan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alexandra Michelle Moreira
- Department of Physical Medicine & Rehabilitation, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Swarnima Vardhan
- Department of Internal Medicine, Yale New Haven Health - Bridgeport Hospital, Bridgeport, CT, USA
| | - Yashar Eshraghi
- Department of Anesthesiology & Critical Care Medicine, Ochsner Health System, New Orleans, LA, USA
| | - Saba Javed
- Department of Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Newaj M Abdullah
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Paul J Christo
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sudhir Diwan
- Department of Pain Medicine, Advanced Spine on Park Avenue, New York City, NY, USA
| | | | - Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Timothy R Deer
- Department of Anesthesiology and Pain Medicine, West Virginia University School of Medicine, Charleston, WV, USA
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Desouza C, Shetty V. Effectiveness of platelet-rich plasma in partial-thickness rotator cuff tears: a systematic review. J ISAKOS 2024; 9:699-708. [PMID: 38641254 DOI: 10.1016/j.jisako.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/09/2024] [Accepted: 04/15/2024] [Indexed: 04/21/2024]
Abstract
IMPORTANCE Partial-thickness rotator cuff tears (PTRCTs) commonly affect overhead athletes, leading to a decline in sports performance. Platelet-rich plasma (PRP) is being explored as an alternative treatment modality for individuals with PTRCTs to reduce discomfort and enhance functional recovery. We conducted a systematic review study of randomized controlled clinical trials to determine the effectiveness of PRP in treating PTRCTs. AIM To determine the effectiveness of PRP in treating PTRCTs. EVIDENCE REVIEW We conducted a comprehensive literature search for randomized controlled trials (RCTs) that compared the effectiveness of PRP with eccentric exercise and placebo injections as treatments for PTRCTs. We searched databases such as the Cochrane Library, Web of Science, PubMed, and EMBASE. The visual analog scale (VAS) score, American Shoulder and Elbow Surgeon (ASES) score, and Constant-Murley Score (CMS) was utilized as an outcome measure. Statistical analysis was performed using RevMan 5.3 software. FINDINGS Our meta-analysis included 12 studies involving 762 patients. At six weeks post-treatment, the PRP group had significantly higher VAS scores compared to the control group, indicating improvement (standard mean difference (SMD): -2.04 [95% confidence interval (CI): -4.00 to -0.08], I2 = 97%, P-value = 0.04). Patients who received PRP showed statistically significant improvements in VAS scores at 3 months and 6 months follow-up (SMD, -1.78 [95% CI: -3.03 to -0.52], I2 = 96%, P-value = 0.005) (SMD: -2.26 [95% CI: -3.77 to -0.76], I2 = 97%, P-value = 0.003). A statistically significant difference was also observed in VAS scores at the long-term 1-year follow-up (SMD: -2.27 [95% CI: -4.07 to -0.47]; I2 = 98%; P-value = 0.031). There were statistically significant differences in ASES scores and CMS scores in the short-term (SMD: 1.21 [95% CI: 0.19 to 2.24], I2 = 96%, P-value = 0.02) (SMD, 2.01 [95% CI: 0.14 to 3.88], I2 = 97%, P-value = 0.04). However, in the long-term ASES and CMS scores did not show any statistical significance (SMD: 2.06 [95% CI: -0.54 to 4.65], I2 = 99%, P-value = 0.12) (SMD: 4.36 [95% CI: -5.48 to 14.21], I2 = 99%, P-value = 0.39). CONCLUSIONS AND RELEVANCE Our findings suggest that PRP treatment is effective in reducing pain for individuals with PTRCTs, providing benefits in the short and long term. However, its impact on functional recovery appears somewhat constrained and doesn't endure over time. Additionally, significant heterogeneity exists among studies, encompassing variations in PRP composition and control group treatments. Consequently, we conclude that compelling evidence for symptom improvement in PTRCT patients following PRP treatment remains elusive. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Clevio Desouza
- SAANVI Orthopaedics, 2003, Sorrento, High Street, Hiranandani Gardens, Powai, Mumbai 400076, India; Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, 400053, India.
| | - Vijay Shetty
- SAANVI Orthopaedics, 2003, Sorrento, High Street, Hiranandani Gardens, Powai, Mumbai 400076, India; Dr L H Hiranandani Hospital, Hiranandani Gardens, Powai, Mumbai, 400076, India
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Dakkak M, Saleem A, Patel D, Yeager M, Oliveira L, Gilot G, Spindler KP. A systematic review of randomized control trials looking at functional improvement of rotator cuff partial thickness tears following platelet-rich-plasma injection: a comparison of glenohumeral joint vs. subacromial bursa vs. intratendinous injection locations. JSES Int 2024; 8:464-471. [PMID: 38707549 PMCID: PMC11064684 DOI: 10.1016/j.jseint.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Background Prior research has demonstrated that platelet-rich plasma (PRP) has shown promising results in the treatment of knee osteoarthritis, lateral epicondylitis, and rotator cuff disease. However, there is a lack of standardization with PRP regarding its use for partial thickness rotator cuff tears (PTRCTs). The primary objective of this review is to assess the location of PRP injections in the shoulder, and how it corresponds to shoulder functional outcomes in PTRCTs. Methods Data sources included randomized controlled trials (RCTs) conducted between January 2010 and September 2021 with the terms PRP, partial thickness rotator cuff tears, intra-articular injections, subacromial injections, and intratendinous injections. Major inclusion criteria: partial thickness rotator cuff tears only, functional outcome scores pre-injection and post-injection, minimum 2-month follow-up time, and nonsurgical PRP injections only. Major exclusion criteria: PRP used as an adjunct therapy, full-thickness rotator cuff tears, and surgical intervention before treatment. Results A total of 8 RCTs were included which utilized PRP injected into the shoulder for PTRCTs. Studies were grouped by the location of the injection with the following breakdown: 1 glenohumeral joint, 4 subacromial bursa, and 3 intratendinous as the site of injection of PRP. Intra-articular PRP showed a 46.2% improvement (P < .05) in the Disabilities of the Arm, Shoulder, and Hand score at 12-month follow-up, however PRP compared to physical therapy had no statistical difference. For subacromial injections, one study showed no statistical difference between hyaluronic acid and PRP vs PRP, but both groups showed improvement compared to normal saline at 3, 6, and 12 months (P < .05). For intratendinous injections, PRP was found to be superior in the Shoulder Pain and Disability Index scores at 66.1% improvement (P < .05) at 3 months and 71.6% at 6 months (P < .05) after two PRP injections when compared to dry needling. Another study showed a statistically significant difference in ASES score when combining LP-PRP injection intratendinous and subacromial bursa when compared to corticosteroid at 3 months. Furthermore, at 6-month follow-up, the PRP group showed significant improvement in the Oxford Shoulder Score compared to a subacromial bursa corticosteroid group 53.8% vs 31.7% (P < .01). Conclusion Based on our review of current literature, there is inconclusive evidence of the ideal location to inject PRP when partial rotator cuff tear is present. Despite PRP showing improved functional outcomes in patients diagnosed with PTRCT regardless of the injection site, more research is needed to figure out the optimal concentration of PRP, frequency of injection, and who are ideal candidates when utilizing PRP for PTRCTs.
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Affiliation(s)
- Michael Dakkak
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Arhum Saleem
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Dev Patel
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Matthew Yeager
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Leonardo Oliveira
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Gregory Gilot
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Kurt P. Spindler
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA
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Silveira A, Lima C, Beaupre L, Chepeha J, Jones A. Shoulder specific exercise therapy is effective in reducing chronic shoulder pain: A network meta-analysis. PLoS One 2024; 19:e0294014. [PMID: 38683828 PMCID: PMC11057978 DOI: 10.1371/journal.pone.0294014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 10/24/2023] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Exercise therapy (ET) is frequently an early treatment of choice when managing shoulder pain, yet evidence on its efficacy to expedite recovery is inconsistent. Moreover, the value of adding adjunct therapies (i.e. injections, manual therapy, electrotherapy) to ET is currently unclear. This study combined both direct and indirect evidence across studies on the effectiveness of ET with/without adjunct therapies compared to usual medical care for adults with chronic shoulder pain. METHODS AND FINDINGS Using a network meta-analysis, randomized control trials comparing ET along with adjunct therapies were identified in MEDLINE, Embase, CINAHL, Sportdiscus, CENTRAL, Conference Proceedings Citation Index-Science, clinicaltrials.gov, and association websites. Outcomes included pain, range of motion (ROM), and health-related quality of life (HRQL) measures in adult patients with chronic shoulder pain. Data analysis used a Frequentist hierarchical model. CINeMA tool assessed the confidence in the results and Cochrane Risk of Bias tool assessed quality of studies. 54 studies primarily from Europe (40.38%) included 3,893 participants who were followed up to 52 weeks. Shoulder-specific ET (Mean difference (MD) = -2.1; 95% confidence interval (CI) = -3.5 to -0.7) or in combination with electro-physical agents (MD = -2.5; 95% CI = -4.2 to -0.7), injections (MD = -2.4; 95% CI = -3.9 to-1.04) or manual therapy (MD = -2.3; 95% CI = -3.7 to -0.8) decreased pain compared to usual medical care. Trends with ROM and HRQL scores were seen; however, only Manual Therapy (MD = -12.7 and 95% CI = -24.4 to -1.0) achieved meaningfully important changes. Sensitivity analysis excluding studies with high risk of bias showed similar results, with exception of injections that did not reach significance (MD = -1.3; 95% CI = -4.3 to 1.7). CONCLUSION(S) Shoulder-specific ET provided pain relief up to 52 weeks. Adjunct therapies to shoulder-specific ET added little value in reducing pain. The quality of evidence varied between moderate and very low.
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Affiliation(s)
- Anelise Silveira
- University of Alberta, School of Public Health, Edmonton, Alberta, Canada
| | - Camila Lima
- University of Alberta, School of Public Health, Edmonton, Alberta, Canada
| | - Lauren Beaupre
- University of Alberta, Faculty of Rehabilitation Sciences, Edmonton, Alberta, Canada
- University of Alberta, Collaborative Orthopaedic Research, Edmonton, Alberta, Canada
| | - Judy Chepeha
- University of Alberta, Collaborative Orthopaedic Research, Edmonton, Alberta, Canada
| | - Allyson Jones
- University of Alberta, Faculty of Rehabilitation Sciences, Edmonton, Alberta, Canada
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Bahadir B, Sarikaya B. Platelet-rich plasma in the management of rotator cuff tendinopathy. Jt Dis Relat Surg 2024; 35:462-467. [PMID: 38727130 PMCID: PMC11128950 DOI: 10.52312/jdrs.2024.1586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 01/28/2024] [Indexed: 05/24/2024] Open
Abstract
Platelet-rich plasma (PRP) is an autologous blood-derived product that has gained significant attention in the treatment of tendinopathies as one of many treatment modalities in the field of regenerative medicine. Rotator cuff pathologies are the leading cause of shoulder pain. Despite the high success rate with conservative treatment and arthroscopic surgical repair, the search for a nonsurgical treatment has made PRP a trending topic recently. The purpose of this article is to review the recent literature data on the possible role of PRP in different rotator cuff pathologies. The limited data in the literature about isolated tendinopathies without a tear (tendonitis and tendinosis) suggests potential benefit from conservative treatment with PRP. Many studies exist for the treatment of rotator cuff tears solely using PRP or as an augmentation to arthroscopic repair. Despite the large number of randomized clinical trials and meta-analyses about the topic, there is no consensus in favor of routine application of PRP in this patient population. The existing reliable evidence of benefit seems to be restricted to its use in only inflammatory tendinopathies with preserved tendon integrity.
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Affiliation(s)
- Batuhan Bahadir
- Ankara Bilkent Şehir Hastanesi, Ortopedi ve Travmatoloji Kliniği, 06800 Çankaya, Ankara, Türkiye.
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Eubank BHF, Sheps DM, Dennett L, Connick A, Bouliane M, Panu A, Harding G, Beaupre LA. A scoping review and best evidence synthesis for treatment of partial-thickness rotator cuff tears. J Shoulder Elbow Surg 2024; 33:e126-e152. [PMID: 38103720 DOI: 10.1016/j.jse.2023.10.027] [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: 09/01/2023] [Revised: 10/24/2023] [Accepted: 10/30/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Rotator cuff disorders include a broad spectrum of pathological conditions including partial-thickness and full-thickness tears. Studies have shown partial-thickness rotator cuff tear (PTRCT) prevalence to be twice that of full-thickness tears. In the working population, PTRCTs are one of the most common causes of shoulder pain and often result in occupational disability due to pain, stiffness, and loss of shoulder function. Treatment of PTRCTs remains controversial. The purpose of this study was to consolidate the existing high-quality evidence on best management approaches in treating PTRCTs using both nonoperative and operative approaches. METHODS A scoping review with best evidence synthesis was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. MEDLINE (OVID), EMBASE (OVID), Cochrane Library (Wiley), SCOPUS, Web of Science Core Collection, CINAHL Plus with Full Text (EBSCOhost), PubMed Central, and Science Direct were searched from 2000 to March 3, 2023. Level 1 studies, and systematic reviews and meta-analyses that included level 1 and 2 studies, were included. RESULTS The search yielded 8276 articles. A total of 3930 articles were screened after removing 4346 duplicates. Application of inclusion criteria resulted in 662 articles that were selected for full-text review. Twenty-eight level 1 studies, 1 systematic review, 4 meta-analyses, and 1 network meta-analyses were included in the best evidence synthesis. Nonoperative strategies included injections (ie, platelet-rich plasma, corticosteroid, prolotherapy, sodium hyaluronate, anesthetic, and atelocollagen), exercise therapy, and physical agents. Operative interventions consisted of débridement, shaving of the tendon and footprint, transtendon repair, and traditional suture anchor repair techniques with and without tear completion. Both nonoperative and operative strategies demonstrated effectiveness at managing pain and functional outcome for PTRCTs. The evidence supports the effectiveness of surgical intervention in treating PTRCTs regardless of arthroscopic technique. CONCLUSION The results of this scoping review do not support superiority of operative over nonoperative management and suggest that both strategies can be effective at managing pain and functional outcome for PTRCTs. Surgery, however, is the most invasive and costly approach, with the highest risk of complications such as infection. Other variables such as patient expectation, treating practitioner bias, or preference may change which modalities are offered and in what sequence.
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Affiliation(s)
- Breda H F Eubank
- Faculty of Health, Community, and Education, Department of Health and Physical Education, Mount Royal University, Calgary, AB, Canada.
| | - David M Sheps
- Division of Orthopaedics, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Liz Dennett
- Health Sciences Librarian, University of Alberta, Edmonton, AB, Canada
| | - Abbie Connick
- Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada
| | - Martin Bouliane
- Division of Orthopaedics, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Anukul Panu
- Division of Radiology & Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Graeme Harding
- Division of Orthopaedics, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Lauren A Beaupre
- Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada
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Ribeiro LP, Curiel-Montero F, Rodrigues-de-Souza DP, Camargo PR, Alburquerque-Sendín F. Assessment of description and implementation fidelity of clinical trials involving exercise-based treatment in individuals with rotator cuff tears: a scoping review. Braz J Phys Ther 2024; 28:101062. [PMID: 38640642 PMCID: PMC11039315 DOI: 10.1016/j.bjpt.2024.101062] [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: 12/01/2022] [Revised: 03/13/2024] [Accepted: 03/27/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND For evidence-based practice, clinicians and researchers can rely on well-conducted randomized clinical trials that exhibit good methodological quality, provide adequate intervention descriptions, and implementation fidelity. OBJECTIVE To assess the description and implementation fidelity of exercise-based interventions in clinical trials for individuals with rotator cuff tears. METHODS A systematic search was conducted in PubMed, Embase, CINAHL, LILACS, Cochrane Library, Web of Science, SCOPUS and SciELO. Randomized clinical trials that assessed individuals with rotator cuff tears confirmed by imaging exam were included. All individuals must have received an exercise-based treatment. The methodological quality was scored with the Physiotherapy Evidence Database (PEDro) scale. The Template for Intervention Description and Replication (TIDieR) checklist and the National Institutes of Health Behaviour Change Consortium (NIHBCC) were used to assess intervention description and implementation fidelity, respectively. RESULTS A total of 13 studies were included. Despite their adequate methodological quality, the description of the intervention was poor with TIDieR scores ranging from 6 to 15 out of 24 total points. The TIDieR highest-scoring item was item 1 (brief name) that was reported in all studies. Considering fidelity, only one of the five domains of NIHBCC (i.e., treatment design) reached just over 50%. CONCLUSION Exercise-based interventions used in studies for individuals with rotator cuff tears are poorly reported. The description and fidelity of the intervention need to be better reported to assist clinical decision-making and support evidence-based practice.
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Affiliation(s)
- Larissa Pechincha Ribeiro
- Laboratory of Analysis and Intervention of the Shoulder Complex, Department of Physical Therapy, Universidade Federal de São Carlos, São Carlos, SP, Brazil
| | - Francisca Curiel-Montero
- Department of Nursing, Pharmacology and Physical Therapy, Universidad de Córdoba, Córdoba, Spain
| | - Daiana Priscila Rodrigues-de-Souza
- Department of Nursing, Pharmacology and Physical Therapy, Universidad de Córdoba, Córdoba, Spain; Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain
| | - Paula Rezende Camargo
- Laboratory of Analysis and Intervention of the Shoulder Complex, Department of Physical Therapy, Universidade Federal de São Carlos, São Carlos, SP, Brazil.
| | - Francisco Alburquerque-Sendín
- Department of Nursing, Pharmacology and Physical Therapy, Universidad de Córdoba, Córdoba, Spain; Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain
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Cooper K, Alexander L, Brandie D, Brown VT, Greig L, Harrison I, MacLean C, Mitchell L, Morrissey D, Moss RA, Parkinson E, Pavlova AV, Shim J, Swinton PA. Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness. Health Technol Assess 2023; 27:1-389. [PMID: 37929629 PMCID: PMC10641714 DOI: 10.3310/tfws2748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy. Review questions (i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies? Methods A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021. Results Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship. Limitations Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made. Conclusion The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence. Future work There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes. Study registration This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review). Funding This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kay Cooper
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Lyndsay Alexander
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - David Brandie
- Sportscotland Institute of Sport, Airthrey Road, Stirling, UK
| | | | - Leon Greig
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Isabelle Harrison
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Colin MacLean
- Library Services, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Laura Mitchell
- NHS Grampian, Physiotherapy Department, Ellon Health Centre, Schoolhill, Ellon, Aberdeenshire, UK
| | - Dylan Morrissey
- William Harvey Research Institute, School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, Bancroft Road, London, UK
| | - Rachel Ann Moss
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Eva Parkinson
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | | | - Joanna Shim
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Paul Alan Swinton
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
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9
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Rossi LA, Piuzzi N, Tanoira I, Brandariz R, Huespe I, Ranalletta M. Subacromial Platelet-Rich Plasma Injections Produce Significantly Worse Improvement in Functional Outcomes in Patients With Partial Supraspinatus Tears Than in Patients With Isolated Tendinopathy. Arthroscopy 2023; 39:2000-2008. [PMID: 37001744 DOI: 10.1016/j.arthro.2023.03.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 03/05/2023] [Accepted: 03/09/2023] [Indexed: 04/23/2023]
Abstract
PURPOSE To compare the effect of subacromial leukocyte-rich platelet-rich plasma (PRP) injections in patients with isolated rotator cuff tendinopathy (RCT) and those with partial-thickness rotator cuff tears (PTRCTs) based on functional outcomes, pain improvement, sleep disturbances, and return to sports. METHODS Between November 2019 and March 2021, 150 patients underwent PRP injections at our institution for refractory rotator cuff tendinopathy and partial rotator cuff tears (105 RCTs and 45 PTRCTs). The American Shoulder and Elbow Surgeons (ASES) score, the visual analog scale (VAS) for pain, the Single Assessment Numeric Evaluation (SANE) and The Pittsburgh Sleep Quality Index were evaluated at 2-, 6-, and 12-month follow-up. Return to sports was also evaluated. An ultrasound examination was performed to evaluate structural outcomes 12 months after the injection. RESULTS The mean age was 36.6 years (±9.08). Overall, the ASES, VAS, SANE, and Pittsburgh scores showed statistical improvement after the injection (P < .01). Specifically, the improvement in the ASES score, which was the primary outcome measure was significantly greater in the group without tears than in the group with PTRCTs at all follow-up times. Moreover, 94% of the patients in the isolated RCT group and 49% in the PTRCTs group achieved a substantial clinical benefit at 12 months follow-up. Ten out of the 50 patients (20%) who received PRP injections due to a partial RC tear underwent surgery due to the lack of clinical improvement. CONCLUSIONS Subacromial PRP injections produced a significant improvement in shoulder function, pain, and sleep disturbances in most patients with RCT refractory to conservative treatment that was maintained at the 12-month follow-up. Moreover, most patients returned to sports at the same level prior to injury. However, improvement in symptoms and functional outcomes was significantly worse in patients who had a PTRCT compared with patients who had an isolated tendinopathy. LEVEL OF EVIDENCE Level II, prospective cohort study.
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Affiliation(s)
- Luciano A Rossi
- Department of Orthopedics and Traumatology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - Nicolás Piuzzi
- Department of Orthopedics and Traumatology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ignacio Tanoira
- Department of Orthopedics and Traumatology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Rodrigo Brandariz
- Department of Orthopedics and Traumatology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ivan Huespe
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Maximiliano Ranalletta
- Department of Orthopedics and Traumatology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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10
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Velasquez Garcia A, Ingala Martini L, Franco Abache A, Abdo G. Role of platelet-rich plasma in the treatment of rotator cuff tendinopathy. World J Orthop 2023; 14:505-515. [PMID: 37485430 PMCID: PMC10359750 DOI: 10.5312/wjo.v14.i7.505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/11/2023] [Accepted: 05/15/2023] [Indexed: 07/18/2023] Open
Abstract
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.
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Affiliation(s)
| | - Liborio Ingala Martini
- Department of Orthopedic Surgery, Hospital IVSS Dr. Luis Ortega, Porlamar 6301, Venezuela
- Department of Orthopedic Surgery, Hospital Clinicas del Este, Los Robles 6301, Venezuela
| | - Andres Franco Abache
- Department of Orthopedic Surgery, Hospital de Especialidades Guayaquil MSP, Guayaquil 090101, Ecuador
| | - Glen Abdo
- Department of Graduate Medical Education, Internal Medicine Residence Program, New York Medical College at St. Mary’s and St. Clare’s, Passaic, NJ 07055, United States
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11
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Abdalla AA, Pendegrass CJ. Biological approaches to the repair and regeneration of the rotator cuff tendon-bone enthesis: a literature review. BIOMATERIALS TRANSLATIONAL 2023; 4:85-103. [PMID: 38283917 PMCID: PMC10817785 DOI: 10.12336/biomatertransl.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/15/2023] [Accepted: 05/05/2023] [Indexed: 01/30/2024]
Abstract
Entheses are highly specialised organs connecting ligaments and tendons to bones, facilitating force transmission, and providing mechanical strengths to absorb forces encountered. Two types of entheses, fibrocartilaginous and fibrous, exist in interfaces. The gradual fibrocartilaginous type is in rotator cuff tendons and is more frequently injured due to the poor healing capacity that leads to loss of the original structural and biomechanical properties and is attributed to the high prevalence of retears. Fluctuating methodologies and outcomes of biological approaches are challenges to overcome for them to be routinely used in clinics. Therefore, stratifying the existing literature according to different categories (chronicity, extent of tear, and studied population) would effectively guide repair approaches. This literature review supports tissue engineering approaches to promote rotator cuff enthesis healing employing cells, growth factors, and scaffolds period. Outcomes suggest its promising role in animal studies as well as some clinical trials and that combination therapies are more beneficial than individualized ones. It then highlights the importance of tailoring interventions according to the tear extent, chronicity, and the population being treated. Contributing factors such as loading, deficiencies, and lifestyle habits should also be taken into consideration. Optimum results can be achieved if biological, mechanical, and environmental factors are approached. It is challenging to determine whether variations are due to the interventions themselves, the animal models, loading regimen, materials, or tear mechanisms. Future research should focus on tailoring interventions for different categories to formulate protocols, which would best guide regenerative medicine decision making.
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Affiliation(s)
- Ahlam A. Abdalla
- Institute of Sport, Exercise and Health (ISEH), Division of Surgery & Interventional Sciences, University College London, London, UK
| | - Catherine J. Pendegrass
- Department of Orthopaedics & Musculoskeletal Science, Division of Surgery & Interventional Sciences, University College London, Brockley Hill, Stanmore, UK
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12
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Johnson AJ, Bradsell H, Frank RM. Use of Injections and Biologics for the Nonoperative Treatment of Rotator Cuff Pathology. Clin Sports Med 2023; 42:53-68. [DOI: 10.1016/j.csm.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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13
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Platelet-rich plasma does not improve clinical results in patients with rotator cuff disorders but reduces the retear rate. A systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022; 31:1940-1952. [PMID: 36496450 DOI: 10.1007/s00167-022-07223-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/04/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To assess whether the use of Platelet-rich plasma (PRP) produces a clinical benefit in patients with rotator cuff disorders, treated either conservatively or surgically. METHODS A systematic review was performed according to PRISMA guidelines on three databases (PubMed, Cochrane Library, Web of Science) to identify randomised controlled trials (RCTs) on the use of PRP in patients with rotator cuff disorders, treated either conservatively or surgically. A meta-analysis was performed on articles reporting results for Constant, UCLA, VAS, SST scores and retear rate. The RoB 2.0 and the modified Coleman Methodology Score were used to assess methodological quality. RESULTS A total of 36 RCTs (20 surgical, 16 conservative) were included, for a total of 2,443 patients. Conservative treatment showed high heterogeneity and no clear consensus in favour of PRP. The meta-analysis of the studies with surgical treatment showed no benefit in using PRP in any of the clinical outcomes, either at the short or medium/long-term follow-up. However, the retear rate was lower with PRP augmentation (p < 0.001). The overall quality of the studies was moderate to high, with the surgical studies presenting a lower risk of bias than the conservative studies. CONCLUSION The use of PRP as augmentation in rotator cuff surgical repair significantly reduces the retear rate. However, no benefits were documented in terms of clinical outcomes. PRP application through injection in patients treated conservatively also failed to present any clear advantage. While there are many studies in the literature with several RCTs of moderate to high quality, the high heterogeneity of products and studies remains a significant limitation to fully understanding PRP potential in this field. LEVEL OF EVIDENCE Level I.
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14
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Saurav S, Aggarwal AN, Shahi P, Kamal S, Bansal K, Singla S. Efficacy of Single Injection of Platelet-Rich Plasma in Shoulder Impingement Syndrome. Cureus 2022; 14:e25727. [PMID: 35812631 PMCID: PMC9270084 DOI: 10.7759/cureus.25727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction To analyze the change in Visual Analog Scale (VAS), QuickDASH score, and the range of motion at the shoulder joint following a single injection of platelet-rich plasma (PRP) in shoulder impingement syndrome. Methods Twenty patients (21 shoulders) of either sex above the age of 18 years with a clinical diagnosis of shoulder impingement having a positive shoulder impingement test (positive Hawkins-Kennedy impingement test and/or positive Neer's impingement sign), ultrasonographic confirmation of shoulder impingement, and a failure to respond to standard non-operative methods for a minimum period of four weeks were included in this prospective interventional study. PRP was injected at the proposed site. At three months after the injection, the changes in the VAS, QuickDASH score, and the range of motion at the shoulder joint were analyzed. Results There were significant changes in the VAS, QuickDASH score, and range of motion at the shoulder joint following a single injection of PRP. Conclusions Platelet-rich plasma (PRP) injection results in a significant decrease in pain and improvement in the range of motion and an overall excellent functional outcome in shoulder impingement syndrome. However, future studies with a bigger sample size and longer follow-up are needed.
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15
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Dyson-Hudson TA, Hogaboom NS, Nakamura R, Terry A, Malanga GA. Ultrasound-guided platelet-rich plasma injection for the treatment of recalcitrant rotator cuff disease in wheelchair users with spinal cord injury: A pilot study. J Spinal Cord Med 2022; 45:42-48. [PMID: 32379581 PMCID: PMC8890529 DOI: 10.1080/10790268.2020.1754676] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Context/Objective: Wheelchair users with spinal cord injury (SCI) have a high risk of developing shoulder pain, caused by rotator cuff disease. Platelet-rich plasma (PRP) is a potential treatment after conservative treatments fail and prior to surgical intervention; however, it has not been tested in wheelchair users who have recalcitrant shoulder pain associated with rotator cuff disease. The objective of this pilot project was to test the safety and potential treatment effect of an ultrasound-guided PRP injection for shoulder pain in the aforementioned population.Design: Prospective, quasi-experimental.Setting: Clinical research center.Participants: Six wheelchair users with SCI (3 paraplegia, 3 tetraplegia) who had chronic shoulder pain due to rotator cuff disease (presence of anterior shoulder pain, positive physical examination tests for rotator cuff disease, and tendinopathy demonstrated by ultrasound) and failed at least six months of conservative treatment.Interventions: Ultrasound-guided PRP injection into pathological shoulder tendons, targeting the supraspinatus. Subjects were provided a standardized stretching and strengthening program and were followed for 4, 8, 12, and 24 weeks post-intervention with outcomes collected at each time-point.Outcome Measures: Wheelchair User's Shoulder Pain Index (WUSPI); pain Numerical Rating Scale (NRS); physical and ultrasound examinations for supraspinatus tendinopathy; 5-point patient global impression of change (PGIC).Results: WUSPI (69.9%, P < 0.001), NRS (49.6%, P < 0.01), and physical exam scores (35.7%, P < 0.01) decreased 24 weeks after treatment. Participants reported overall improvement in their status as a result of the treatment. No adverse events were noted, and no changes in ultrasound markers for tendinopathy were observed.Conclusion: A single, ultrasound-guided PRP injection into the supraspinatus tendon, followed by a stretching and strengthening exercise program, was safe and provided improvements in shoulder pain outcome measures in this sample for 24 weeks. Lack of blinding, short-term follow-up, and a suitable control group warrant a larger randomized controlled trial.Trial Registration: NCT01355549.
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Affiliation(s)
- Trevor A. Dyson-Hudson
- Kessler Foundation, West Orange, New Jersey, USA,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA,Correspondence to: Trevor A. Dyson-Hudson, Kessler Foundation, 1199 Pleasant Valley Way, West Orange, New Jersey07052, USA.
| | - Nathan S. Hogaboom
- Kessler Foundation, West Orange, New Jersey, USA,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Reina Nakamura
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Alon Terry
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Gerard A. Malanga
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA,Kessler Institute for Rehabilitation, West Orange, New Jersey, USA,New Jersey Regenerative Institute, LLC, Cedar Knolls, New Jersey, USA
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16
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Van Schaik KD, Lee KS. Orthobiologics: Diagnosis and Treatment of Common Tendinopathies. Semin Musculoskelet Radiol 2021; 25:735-744. [PMID: 34937114 DOI: 10.1055/s-0041-1735475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Orthobiologics, including platelet-rich plasma, prolotherapy, and mesenchymal stem cells, are seeing increasing use in the treatment of osteoarthritis (OA), muscle injury, and tendinopathy. This article reviews the biology and applications of orthobiologics in tendons, muscles, and joints, and focuses on platelet-rich plasma (PRP). Clinical evidence-based literature related to the use of PRP in the treatment of rotator cuff injury, lateral epicondylosis, Achilles tendinopathy, plantar fasciitis, knee OA, and acute muscle injury are discussed.
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Affiliation(s)
- Katherine D Van Schaik
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kenneth S Lee
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.,Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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17
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Barman A, Mishra A, Maiti R, Sahoo J, Thakur KB, Sasidharan SK. Can platelet-rich plasma injections provide better pain relief and functional outcomes in persons with common shoulder diseases: a meta-analysis of randomized controlled trials. Clin Shoulder Elb 2021; 25:73-89. [PMID: 34823313 PMCID: PMC8907495 DOI: 10.5397/cise.2021.00353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/26/2021] [Indexed: 11/26/2022] Open
Abstract
Background To evaluate the efficacy of autologous platelet-rich plasma (PRP) injections in the treatment of common shoulder diseases. Methods The PubMed, Medline, and Central databases and trial registries were searched from their inception to October 2020 for randomized controlled trials of autologous PRP injections for shoulder diseases versus placebo or any control intervention. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed in the selection, analysis, and reporting of findings. The primary outcome was pain intensity (visual analog scale), and secondary outcomes were changes in function and quality of life (QoL). Results A total of 17 randomized controlled trials of PRP versus control were analyzed. From 8–12 weeks to ≥1 year, PRP injections were associated with better pain relief and functional outcomes than control interventions. PRP injections were also associated with greater QoL, with an effect size of 2.61 (95% confidence interval, 2.01–14.17) at medium-term follow-up. Compared with placebo and corticosteroid injections, PRP injections provided better pain relief and functional improvement. In subgroup analyses, trials in which PRP was prepared by the double centrifugation technique, the platelet concentration in the PRP was enriched ≥5 times, leucocyte-rich PRP was used, or an activating agent was used before application reported the most effective pain relief at 6–7 months. Conclusions PRP injections could provide better pain relief and functional outcomes than other treatments for persons presenting with common shoulder diseases. PRP injections have a greater capacity to improve shoulder-related QoL than other interventions.
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Affiliation(s)
- Apurba Barman
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Archana Mishra
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
| | - Rituparna Maiti
- Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Jagannatha Sahoo
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Kaustav Basu Thakur
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Sreeja Kamala Sasidharan
- Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Bhubaneswar, India
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18
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Condron NB, Kester BS, Tokish JM, Zumstein MA, Gobezie R, Scheibel M, Cole BJ. Nonoperative and Operative Soft-Tissue, Cartilage, and Bony Regeneration and Orthopaedic Biologics of the Shoulder: An Orthoregeneration Network (ON) Foundation Review. Arthroscopy 2021; 37:3200-3218. [PMID: 34293441 DOI: 10.1016/j.arthro.2021.06.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/16/2021] [Indexed: 02/02/2023]
Abstract
Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electro-magnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the shoulder including the rotator cuff tendons, glenohumeral articular cartilage, glenoid labrum, the joint capsule, and bone. Promising and established treatment modalities include hyaluronic acid (HA); platelet-rich plasma (PRP) and platelet rich concentrates (PRC); bone marrow aspirate (BMA) comprising mesenchymal stromal cells (MSCs alternatively termed medicinal signaling cells and frequently, misleadingly labelled "mesenchymal stem cells"); MSC harvested from adipose, umbilical, or placental sources; factors including vascular endothelial growth factors (VEGF), basic fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), transforming growth factor-beta (TGFβ), bone morphogenic protein (BMP), and matrix metalloproteinases (MMPs); prolotherapy; pulsed electromagnetic field therapy; microfracture and other marrow-stimulation techniques; biologic resurfacing using acellular dermal allografts, allograft Achilles tendons, allograft lateral menisci, fascia lata autografts, and porcine xenografts; osteochondral autograft or allograft); and autologous chondrocyte implantation (ACI). Studies involving hyaluronic acid, platelet rich plasma, and medicinal signaling cells of various origin tissues have shown mixed results to-date as isolated treatments and as surgical adjuncts. Despite varied results thus far, there is great potential for improved efficacy with refinement of current techniques and translation of burgeoning preclinical work. LEVEL OF EVIDENCE: Level V, expert opinion.
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Affiliation(s)
| | | | | | - Matthias A Zumstein
- Orthopaedics Sonnenhof, Bern, and Department of Orthopaedics and Traumatology, University of Bern, Inselspital, Bern, Switzerland
| | | | - Markus Scheibel
- Department for Shoulder and Elbow Surgery, Schulthess Clinic, Zurich, Switzerland; Center for Musculoskeletal Surgery, Charité-Universitaetsmedizin, Berlin, Germany
| | - Brian J Cole
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A..
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19
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Prodromos CC, Finkle S, Prodromos A, Chen JL, Schwartz A, Wathen L. Treatment of Rotator Cuff Tears with platelet rich plasma: a prospective study with 2 year follow-up. BMC Musculoskelet Disord 2021; 22:499. [PMID: 34051761 PMCID: PMC8164813 DOI: 10.1186/s12891-021-04288-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 04/21/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Surgical treatment of full-thickness rotator cuff (RC) tears is associated with generally good results. There is no consensus regarding treatment of partial thickness tears that fail conservative treatment. The purpose of this study was to look at the efficacy and confirm the safety of dual injection PRP into the shoulder of patients with rotator cuff pathology who have failed conservative treatment with followup to two years. METHODS Seventy-one shoulders with MRI confirmed, rotator cuff pathology who failed conservative treatment, had dual PRP injection into the rotator cuff. Global improvement, Quick DASH and VAS scores were collected at 6, 12, and 24 months after treatment and comparison of means was used to analyze changes. RESULTS No adverse events were seen in any patient. Based on global rating scores positive results were seen in 77.9 % of patients at 6 months, 71.6 % at 1 year, and 68.8 % of patients at 2 years. Mean VAS scores improved from 50.2 [CI 44.4-56.0] pre-injection to 26.2 [CI 19.5-32.9] at 6 months, 22.4[CI 16.1-28.7] at 1 year and 18.2 [CI 12.3-24.1] at 2 years (p < 0.0001 for all). The mean Q- DASH scores (0-100, 100 worse) improved from 39.2 [CI 34.3-44.1] for all patients before treatment to 20.7[CI 15.0-26.4] at 6 months, 18.0[CI 12.9-23.1] at 1 year, and 13.8 [CI 8.4-18.8] at 2 years (p < 0.0001 for all). No patient with partial tear had clinical evidence of progression to full thickness tear. When separated into subgroups based on rotator cuff status, all subgroups showed improvement. Patients in the > 50 % partial tear group had the best overall improvement based on Global Rating scores while those in the tendinitis group had the poorest outcomes. CONCLUSIONS PRP injection is a safe and effective treatment for RC cuff injury in patients who have failed conservative treatment of activity modification and physical therapy without deterioration of results two years after treatment. Better results are obtained with greater structural tendon damage than in shoulders with inflammation without structural damage. TRIAL REGISTRATION This is not a clinical trial.
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Affiliation(s)
- Chadwick C Prodromos
- Illinois Sportsmedicine and Orthopaedic Centers, 1714 Milwaukee Ave, 60025, Glenview, IL, USA.
| | - Susan Finkle
- Illinois Sportsmedicine and Orthopaedic Centers, 1714 Milwaukee Ave, 60025, Glenview, IL, USA
| | - Alexandra Prodromos
- Illinois Sportsmedicine and Orthopaedic Centers, 1714 Milwaukee Ave, 60025, Glenview, IL, USA
| | - Jasmine Li Chen
- Illinois Sportsmedicine and Orthopaedic Centers, 1714 Milwaukee Ave, 60025, Glenview, IL, USA
| | - Aron Schwartz
- Illinois Sportsmedicine and Orthopaedic Centers, 1714 Milwaukee Ave, 60025, Glenview, IL, USA
| | - Lucas Wathen
- Illinois Sportsmedicine and Orthopaedic Centers, 1714 Milwaukee Ave, 60025, Glenview, IL, USA
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20
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Thu AC, Kwak SG, Shein WN, Htun LM, Htwe TTH, Chang MC. Comparison of ultrasound-guided platelet-rich plasma injection and conventional physical therapy for management of adhesive capsulitis: a randomized trial. J Int Med Res 2021; 48:300060520976032. [PMID: 33296615 PMCID: PMC7731701 DOI: 10.1177/0300060520976032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE We evaluated the effect of ultrasound (US)-guided injection of platelet-rich plasma (PRP) into the shoulder joint in patients with adhesive capsulitis (AC) and compared its effect with that of conventional physiotherapy (CPT). METHODS Sixty-four subjects with AC were included and randomly allocated into two groups, as follows: PRP (n=32; intra-articular [IA] PRP [4 mL] was injected); and CPT (n=32; short wave diathermy and exercise therapy were performed at three sessions/week for 6 weeks). Treatment outcomes evaluated therapeutic effectiveness before and at 1, 3, and 6 weeks after PRP injection and CPT initiation. RESULTS Subjects in both groups showed a significant decrease in the visual analogue scale score for pain and shoulder and hand scores, and they a significant increase in shoulder passive range of motion at all evaluation time points. There was no significant difference in the measured outcomes between the two groups. However, there was less acetaminophen consumption after IA PRP injection compared with that after CPT. CONCLUSIONS IA PRP injection is a useful option for treating patients with AC, particularly those who have low therapeutic compliance for exercise therapy or have contraindications for corticosteroid injection or oral pain reduction medication.
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Affiliation(s)
- Aung Chan Thu
- Department of Physical Medicine and Rehabilitation, University of Medicine, Mandalay, Myanmar
| | - Sang Gyu Kwak
- Department of Medical Statistics, College of Medicine, Catholic University of Daegu, Daegu, South Korea
| | - Win Nyi Shein
- Department of Physical Medicine and Rehabilitation, University of Medicine, Mandalay, Myanmar
| | - La Min Htun
- Department of Physical Medicine and Rehabilitation, National Rehabilitation Hospital, Yangon, Myanmar
| | - Thae Thae Han Htwe
- Department of Preventive and Social Medicine, University of Medicine, Mandalay, Myanmar
| | - Min Cheol Chang
- Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu, Republic of Korea
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21
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A. Hamid MS, Sazlina SG. Platelet-rich plasma for rotator cuff tendinopathy: A systematic review and meta-analysis. PLoS One 2021; 16:e0251111. [PMID: 33970936 PMCID: PMC8109792 DOI: 10.1371/journal.pone.0251111] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/20/2021] [Indexed: 01/01/2023] Open
Abstract
Shoulder rotator cuff tendinopathy is a common debilitating condition that affects a person daily function and the quality of life. Despite its frequent occurrence, the best treatment is still inconclusive. This review assessed the clinical effect of platelet-rich plasma injection for rotator cuff tendinopathy. A systematic literature search was conducted using CINAHL, Medline, SCOPUS, SPORTSDiscus and Web of Science databases to retrieve articles published in peer-reviewed journals until December 2020. Randomised controlled trials (RCTs), which compared clinical effects of PRP injection to the usual care among adults diagnosed with rotator cuff conditions were reviewed. The main outcomes of interest were changes in shoulder pain symptoms and shoulder functions. All variables were analysed using random effects meta-analyses. Eight RCTs were reviewed in this study. The risk of bias for randomization was low for 6 RCTs, one study had unclear risk and the other was a high risk. Studies vary on the PRP techniques including preparation and injections. Moreover, the control intervention also differs. Four studies compared PRP with normal saline injection while in the remaining 4 RCTs the control intervention were rehabilitation program and dry needling. Meta-analysis of selected studies showed that PRP injection was safe and effective intervention for long-term pain control and shoulder function in patients with RC disorders.
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Affiliation(s)
| | - Shariff Ghazali Sazlina
- Faculty of Medicine and Health Sciences, Department of Family Medicine, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
- Malaysian Research Institute on Ageing (MyAgeing), Universiti Putra Malaysia, Serdang, Selangor, Malaysia
- * E-mail:
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Xiang XN, Deng J, Liu Y, Yu X, Cheng B, He HC. Conservative treatment of partial-thickness rotator cuff tears and tendinopathy with platelet-rich plasma: A systematic review and meta-analysis. Clin Rehabil 2021; 35:1661-1673. [PMID: 33896214 DOI: 10.1177/02692155211011944] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess the effect of platelet-rich plasma as a conservative therapy in individuals with partial-thickness rotator cuff tears or tendinopathy on pain, and function. DATA SOURCES Embase, MEDLINE, CENTRAL, Web of Science, CINAHL, PEDro, and the grey literature (to 31 March 2021). METHODS Randomized controlled trials in English that reported short-term (6 ± 1 months), or long-term (⩾1 year) outcomes (shoulder pain or function) were conducted. Two independent reviewers screened the literature, completed the assessment of the Cochrane's risk of bias and extracted the data. Mean difference or standardized mean difference was used for continuous data. Heterogeneity was identified with I2 test. RESULTS A total of 11 studies were eligible, and nine studies (n = 629) were included in this meta-analysis, that showed statistically significant short-term effects of platelet-rich plasma on pain relief (MD = -1.56; 95% CI -2.82 to -0.30), Constant-Murley score (MD = 16.48; 95% CI 12.57 to 20.40), and Shoulder Pain and Disability Index (MD = -18.78; 95% CI -36.55 to -1.02). Nonetheless, no long-term effect was observed on pain and function, except Constant-Murley score (MD = 24.30; 95% CI 23.27 to 25.33). The results of minimal important difference reached the minimal clinically important difference, except American Shoulder and Elbow Surgeons. For subgroup analysis, differences of pain relief were statistically significant in platelet-rich plasma-treated groups with double centrifugation, single injection, and post-injection rehabilitation. CONCLUSION Our results suggested platelet-rich plasma had positive effects on pain relief and functional improvement for partial-thickness rotator cuff tears and rotator cuff tendinopathy, although the effects may not last for a long time.
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Affiliation(s)
- Xiao-Na Xiang
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, P. R. China.,School of Rehabilitation Sciences, West China School of Medicine, Sichuan University, Chengdu, P. R. China.,Rehabilitation Medicine Key Laboratory of Sichuan Province, Chengdu, P. R. China
| | - Jie Deng
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, P. R. China
| | - Yan Liu
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, P. R. China
| | - Xi Yu
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, P. R. China.,School of Rehabilitation Sciences, West China School of Medicine, Sichuan University, Chengdu, P. R. China
| | - Biao Cheng
- Department of Burn & Plastic Surgery, General Hospital of Southern Theatre Command, PLA, Guangzhou, P. R. China
| | - Hong-Chen He
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, P. R. China.,School of Rehabilitation Sciences, West China School of Medicine, Sichuan University, Chengdu, P. R. China.,Rehabilitation Medicine Key Laboratory of Sichuan Province, Chengdu, P. R. China
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23
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Zhang C, Wang J, Wang L, Xie Y, Sun F, Jiang W, Miyamoto A, Lei L. The effect of physiotherapy in rotator cuff injury patients with platelet-rich plasma: study protocol of a non-randomized controlled trial. BMC Musculoskelet Disord 2021; 22:292. [PMID: 33743650 PMCID: PMC7981950 DOI: 10.1186/s12891-021-04171-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/15/2021] [Indexed: 11/10/2022] Open
Abstract
Background The study aims to identify whether Platelet-rich plasma (PRP) combined with early physiotherapy has an advantage over PRP alone for rotator cuff injury patients, regarding pain release, function score, tear size, and quality of life improvement. Methods This is a single-center prospective non-randomized study implemented in July 2019 at the Affiliated Hospital of Southwest Medical University in Sichuan. Three hundred-forteen patients with rotator cuff injury aged over 18 years were recruited. Participants were assigned to the experiment group (PRP plus physiotherapy) or control group (PRP) by their desire. We used the Constant-Murley score to assess the shoulder function, the Visual Analogue Scale to evaluate shoulder pain, and the MOS Item Short-form Health Survey (SF-12) to measure the quality of life. MRI was applied to measure tear size, and the follow-up duration is 12 months. Discussion Our findings will give information on the effects of PRP and physiotherapy on rotator cuff injuries. Physiotherapy might be added to improve the effects of PRP in patients with rotator cuff injuries. Trial registration This study was registered in the Chinese clinical trial registry on September 1st, 2019 (ChiCTR1900025563). Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04171-2.
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Affiliation(s)
- Chi Zhang
- Department of Rehabilitation, The Affiliated Hospital of Southwest Medical University, 25 Tai Ping Road, Luzhou, Sichuan, 646000, People's Republic of China.,Rehabilitation Medicine Department, The Southwest Medical University, Luzhou, Sichuan, People's Republic of China
| | - Jianxiong Wang
- Department of Rehabilitation, The Affiliated Hospital of Southwest Medical University, 25 Tai Ping Road, Luzhou, Sichuan, 646000, People's Republic of China.,Rehabilitation Medicine Department, The Southwest Medical University, Luzhou, Sichuan, People's Republic of China
| | - Li Wang
- Department of Rehabilitation, The Affiliated Hospital of Southwest Medical University, 25 Tai Ping Road, Luzhou, Sichuan, 646000, People's Republic of China.,Rehabilitation Medicine Department, The Southwest Medical University, Luzhou, Sichuan, People's Republic of China
| | - Yujie Xie
- Department of Rehabilitation, The Affiliated Hospital of Southwest Medical University, 25 Tai Ping Road, Luzhou, Sichuan, 646000, People's Republic of China.,Rehabilitation Medicine Department, The Southwest Medical University, Luzhou, Sichuan, People's Republic of China
| | - Fuhua Sun
- Department of Rehabilitation, The Affiliated Hospital of Southwest Medical University, 25 Tai Ping Road, Luzhou, Sichuan, 646000, People's Republic of China.,Rehabilitation Medicine Department, The Southwest Medical University, Luzhou, Sichuan, People's Republic of China
| | - Wei Jiang
- Department of Rehabilitation, The Affiliated Hospital of Southwest Medical University, 25 Tai Ping Road, Luzhou, Sichuan, 646000, People's Republic of China.,Rehabilitation Medicine Department, The Southwest Medical University, Luzhou, Sichuan, People's Republic of China
| | - Akira Miyamoto
- Department of Physical Therapy, Faculty of Rehabilitation of Kobe International University, Kobe, Japan
| | - Lei Lei
- Department of Rehabilitation, The Affiliated Hospital of Southwest Medical University, 25 Tai Ping Road, Luzhou, Sichuan, 646000, People's Republic of China. .,Rehabilitation Medicine Department, The Southwest Medical University, Luzhou, Sichuan, People's Republic of China.
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Oudelaar BW, Huis In 't Veld R, Ooms EM, Schepers-Bok R, Nelissen RGHH, Vochteloo AJH. Efficacy of Adjuvant Application of Platelet-Rich Plasma After Needle Aspiration of Calcific Deposits for the Treatment of Rotator Cuff Calcific Tendinitis: A Double-Blinded, Randomized Controlled Trial With 2-Year Follow-up. Am J Sports Med 2021; 49:873-882. [PMID: 33566629 DOI: 10.1177/0363546520987579] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Needle aspiration of calcific deposits (NACD) is a frequently used treatment for rotator cuff calcific tendinitis (RCCT). However, a substantial number of patients experience recurrent or persisting shoulder symptoms after NACD. PURPOSE To compare the effects of adjuvant application of platelet-rich plasma (PRP) after NACD (NACP+PRP) with those of conventional NACD with corticosteroids (NACD+corticosteroids) on pain, shoulder function, and quality of life (QoL). STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS In a single-center, double-blinded, randomized controlled trial, 80 adults with symptomatic RCCT were randomly allocated to receive NACD+corticosteroids or NACD+PRP. Pain, shoulder function, and QoL were assessed at baseline; 6 weeks; and 3, 6, 12, and 24 months after treatment using a numeric rating scale for pain (NRS); the Constant-Murley score (CMS); the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH); the Oxford Shoulder Score (OSS); and the EuroQol 5-dimension scale (EQ-5D). Additionally, resorption of calcific deposits and the integrity of rotator cuff tendons were assessed by using standard radiographs and ultrasound examination, respectively. The results were analyzed using noninferiority analysis for NRS scores and a mixed model for repeated measures. RESULTS Eighty patients were included (48 female; mean age, 49 ± 6 years; 41 patients in the NACD+PRP group). Both groups showed improvement of clinical scores at the 2-year follow-up (P < .001 for all clinical scores). NACD+PRP was found to be noninferior to NACD+corticosteroids with regard to the mean decrease of NRS scores (4.34 vs 3.56; P = .003). Mixed-model analysis showed a significant difference in favor of NACD+PRP (CMS, P < .001; DASH, P = .002; OSS, P = .010; EQ-5D, P < .001). However, clinically relevant differences in favor of NACD+PRP were only seen at the 6-month follow-up for NRS and CMS scores, whereas at the 6-week follow-up a clinically relevant difference in favor of NACD+corticosteroids was found for all clinical scores except for the NRS. Full resorption of calcific deposits was present in 84% of the NACD+PRP group compared with 66% in the NACD+corticosteroids group (P = .081). In the NACD+PRP group, 10 (24%) patients required a second NACD procedure compared with 19 (49%) patients in the NACD+corticosteroids group (P = .036). Six complications, of which 5 were frozen shoulders, occurred in the NACD+PRP group compared with 1 complication in the NACD+corticosteroids group (P = .11). CONCLUSION NACD+PRP resulted in worse clinical scores at the 6-week follow-up but better clinical scores at the 6-month follow-up compared with NACD+corticosteroids. At the 1- and 2-year follow-ups, the results were comparable between groups. Furthermore, PRP seemed to reduce the need for additional treatments but was associated with more complications. In conclusion, NACD+corticosteroids had a favorable early effect on pain and function combined with low comorbidity. Thus, it remains the treatment of choice for patients with RCCT. REGISTRATION NCT02173743 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Bart W Oudelaar
- Centre for Orthopaedic Surgery OCON, Hengelo, the Netherlands
| | | | - Edwin M Ooms
- Centre for Orthopaedic Surgery OCON, Hengelo, the Netherlands
| | | | - Rob G H H Nelissen
- Department of Orthopaedic Surgery, Leiden University Medical Center (LUMC), Leiden, the Netherlands
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Efficacy of platelet-rich plasma injection in comparison to physical therapy for treatment of chronic partial supraspinatus tear. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2021. [DOI: 10.1186/s43166-021-00058-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Supraspinatus tendon is a part of the rotator cuff of the shoulder, partial or full-thickness tear can affect the tendon secondary to trauma or repeated microtrauma. The aim of the present study is to evaluate the efficacy of platelet-rich plasma (PRP) injection in comparison to physical therapy for treatment of chronic partial supraspinatus tears.
Results
At the beginning of the study, there were no significant differences between both groups in all parameters: (a) PRP injection had significantly improved the visual analog scale (VAS), disabilities of arm, shoulder and hand scale (DASH) and shoulder range of motion (ROM) but not size of tear at 6 and 12 weeks post-injection in comparison to baseline recordings; (b) physical therapy had significantly improved VAS, DASH but not shoulder ROM nor size of tear at 6 and 12 weeks post-injection in comparison to baseline recordings; and (c) PRP injection was superior to physical therapy in the improvement of VAS, shoulder ROM, and DASH score.
Conclusion
The US-guided PRP injection is superior to physical therapy in improving pain, ROM, and function in treatment of partial thickness tear of supraspinatus tendon.
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26
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Niazi GE, Hassan MS, Elfawy DM. Ultrasound-guided injection of platelet-rich plasma (PRP) in rotator cuff tendinopathy: effect on patients’ symptoms and supraspinatus tendon thickness. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00221-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Abstract
Background
Rotator cuff tendinopathy is considered a major cause of shoulder pain and disability that is increasing substantially with age affecting more than half of the general population by the age of 60 years. This study aims to assess the effect of ultrasound-guided injection of platelet-rich plasma on patient symptoms and supraspinatus tendon thickness in cases of rotator cuff tendinopathy.
Results
This was a single-arm interventional study conducted on 30 patients with age ranging between 27 and 54 years old. Following US-guided injection of PRP, patients were evaluated clinically using the Shoulder Pain and Disability Index (SPADI) scoring system and radiologically using ultrasonographic supraspinatus tendon thickness measurements at 4, 8, 12, and 24 weeks. Our study showed remarkably noticeable changes when comparing the pre-injection and post-injection SPADI scoring system. There is highly statistically significant pain and disability score and percentage improvement, yet on the other hand, the radiological improvement shows no statistically significant difference found between baseline tendon thickness and its follow-up at 4, 8, and 12 weeks while only there was a statistically significant decrease in tendon thickness found at 24 weeks with P value = 0.043.
Conclusions
The ultrasound-guided PRP injection for supraspinatus tendinopathy cases is a safe, cheap, and easily prepared outpatient procedure which showed competitive, promising, and well-proved results when compared to other modality outcomes such as conventional surgeries, arthroscopic procedures, and physiotherapy.
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Lui M, Shih W, Yim N, Brandstater M, Ashfaq M, Tran D. Systematic Review and Meta-Analysis of Nonoperative Platelet-Rich Plasma Shoulder Injections for Rotator Cuff Pathology. PM R 2020; 13:1157-1168. [PMID: 33131197 DOI: 10.1002/pmrj.12516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 09/29/2020] [Accepted: 10/16/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Platelet-rich plasma (PRP) injections have been introduced to augment the recovery of patients with shoulder pathology. Although multiple studies have been published, no large-scale trials or meta-analyses have assessed the efficacy of nonoperative shoulder PRP injection. OBJECTIVE To assess the efficacy of nonoperative PRP shoulder injection in rotator cuff pathology for pain as measured by the visual analog scale (VAS) and range of motion (ROM). DESIGN Two authors independently screened the Medline and Cochrane databases to include prospective studies that reported VAS and ROM outcomes for nonoperative shoulder PRP injections for rotator cuff pathology. Study quality was assessed using the revised Cochrane Collaboration risk-of-bias tool and modified Downs and Black checklist. Subsequent meta-analysis was performed to determine the effect of nonoperative PRP injections on pain and ROM 3 to 12 months after intervention. RESULTS Six studies met systematic review criteria. The included studies used different PRP formulations (concentration, leukocyte count), injection protocols (approach, injection number), and varied study designs. Three studies concluded that PRP provided no significant benefit for pain and ROM when compared to physical therapy. Within-group meta-analysis of six fairly heterogeneous studies (I2 77.8%) demonstrated a statistically significant (P < .001) improvement in pain 3 to 12 months after PRP injection. Within-group meta-analysis for four studies for shoulder flexion and abduction was found to be too heterogeneous to derive meaningful results. CONCLUSION There is a limited quantity of high-quality studies that assess the efficacy of nonoperative PRP shoulder injection for pain and ROM. Systematic review of PRP injections did not demonstrate an improvement in pain or ROM compared to physical therapy. Although within-group meta-analysis of nonoperative PRP statistically showed that nonoperative PRP improved pain, the lack of adequate negative controls precludes the ability to conclude whether improvements were due to natural recovery or nonoperative PRP.
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Affiliation(s)
- Mickey Lui
- Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center, Loma Linda, CA, USA.,Department of Physical Medicine and Rehabilitation, VA Loma Linda Healthcare System, Loma Linda, CA, USA
| | - Wendy Shih
- School of Public Health, Loma Linda University, Loma Linda, CA, USA
| | - Nicole Yim
- Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Murray Brandstater
- Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Majid Ashfaq
- Department of Physical Medicine and Rehabilitation, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Duc Tran
- Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center, Loma Linda, CA, USA
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Loescher J, Guthmann R, Auten B. Platelet-rich plasma injection for rotator cuff disease. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2020; 66:824-826. [PMID: 33208423 PMCID: PMC8302438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Jeremy Loescher
- Resident and is a family physician at Advocate Illinois Masonic Medical Center in Chicago.
| | - Richard Guthmann
- Resident and is a family physician at Advocate Illinois Masonic Medical Center in Chicago
| | - Beth Auten
- Health & Human Services Librarian at the University of North Carolina at Charlotte
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Abstract
Biologics are a growing field that has shown immense promise for the treatment of musculoskeletal conditions both in orthopedic sports medicine and interventional pain management. These procedures utilize injection of supraphysiologic levels of platelets and growth factors to invoke the body's own inflammatory cascade to augment the healing of many bony and soft tissue conditions. While many patients improve with conservative care, there is a need to address the gap between those that improve with rehabilitation alone and those who ultimately require operative management. Orthobiologic procedures have the potential to fill this void. The purpose of this review is to summarize the basic science, evidence for use, and post-injection rehabilitation concepts of platelet-rich plasma (PRP) and mesenchymal stromal cells (MSCs) as they pertain to joints, tendons, ligaments, and the spine.
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Affiliation(s)
- Robert L Bowers
- Department of Physical Medicine and Rehabilitation, Emory University School of Medicine, Atlanta, GA; Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA.
| | - Wesley D Troyer
- Department of Physical Medicine and Rehabilitation, Emory University School of Medicine, Atlanta, GA; Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA
| | - Rudolph A Mason
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA; Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kenneth R Mautner
- Department of Physical Medicine and Rehabilitation, Emory University School of Medicine, Atlanta, GA; Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA
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A Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17186863. [PMID: 32962199 PMCID: PMC7558823 DOI: 10.3390/ijerph17186863] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 12/16/2022]
Abstract
Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.
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Influence of Acromial Morphologic Characteristics and Acromioclavicular Arthrosis on the Effect of Platelet-Rich Plasma on Partial Tears of the Supraspinatus Tendon. AJR Am J Roentgenol 2020; 215:954-962. [PMID: 32755169 DOI: 10.2214/ajr.19.22331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE. The purposes of this study were to determine the medium-term effect of ultrasound-guided infiltration of platelet-rich plasma (PRP) on partial tears of the supraspinatus tendon (SST) and to identify prognostic indicators of an unfavorable outcome. SUBJECTS AND METHODS. Over a period of 4 years, patients with a partial SST tear smaller than 1.5 cm referred for ultrasound-guided PRP infiltration (1 mL) for shoulder pain lasting more than 3 months were recruited consecutively. MRI was used to analyze the type of acromion and presence of acromioclavicular (AC) arthrosis. Primary (size of the tear and associated bursitis) and secondary (mobility and pain) results were collected at 3 months. RESULTS. The study included 128 patients (66 men, 62 women; mean age, 48.3 years; range, 20-59 years). At 3 months, favorable evolution of the tear repair was recorded in 71.1% (91/128) of patients and resolution of bursitis in 66.7% (42/63). Changes in tear size had large effect sizes (Cohen d ≥ 1.16), as did pain and shoulder mobility (Cohen d ≥ 0.95). The strongest predictors of unfavorable evolution of tear and bursitis were type 3 acromion and types 1 and 2 acromion with AC arthrosis (p < 0.001; β = 20.412). CONCLUSION. Ultrasound-guided PRP infiltration of partial tears of the SST relieves pain and improves shoulder mobility, but its effect on the size of the tear is influenced by the morphologic characteristics of the acromion and the presence of AC arthrosis. The effect of PRP is insufficient in patients with a type 3 acromion or severe AC arthrosis.
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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: 13] [Impact Index Per Article: 3.3] [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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Effectiveness of Platelet-Rich Plasma Injection in Rotator Cuff Tendinopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Diagnostics (Basel) 2020; 10:diagnostics10040189. [PMID: 32231127 PMCID: PMC7235747 DOI: 10.3390/diagnostics10040189] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/24/2020] [Accepted: 03/27/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND To investigate the effectiveness of platelet-rich plasma (PRP) injection among patients with rotator cuff tendinopathy in comparison with sham injection, no injection, or physiotherapy alone. METHODS From the earliest records to November 1, 2018, all published or unpublished randomized controlled trial (RCTs) comparing PRP injection with a control group (sham injection, no injection, or physiotherapy alone) in patients with rotator cuff tendinopathy were included. Eligible trials were included from the search results of electronic databases including PubMed, EMBASE, Scopus, The Cochrane Library, as well as the bibliographies of relevant trials. Five RCTs were enrolled in our meta-analysis. Two authors independently assessed the quality of RCTs with the Cochrane risk of bias tool. We designated pain reduction as the primary outcome and functional improvement as the secondary outcome. Standardized mean difference (SMD) was applied for random-effect meta-analysis. RESULTS In the short term (3-6 weeks) and medium term (12 weeks), the effectiveness of PRP injection and control group was indistinguishable in terms of both outcomes (pain reduction and functional improvement). Nevertheless, PRP injection led to significant long-term (>24 weeks) pain relief (SMD: 0.42, 95% confidence interval (CI): 0.12-0.72, without heterogeneity). For functional improvement in the long term, PRP injection was not more effective than the control group (SMD: 1.20, 95% CI: -0.20-2.59, with heterogeneity). CONCLUSIONS PRP injection may provide benefit over the control group (sham injection, no injection, or physiotherapy alone) in reducing pain at long-term follow-up for patients with rotator cuff tendinopathy.
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Schwitzguebel AJ, Kolo FC, Tirefort J, Saffarini M, Lädermann A. Efficacy of Platelet-Rich Plasma for the Treatment of Interstitial Supraspinatus Tears: Response. Am J Sports Med 2020; 48:NP9-NP10. [PMID: 31877106 DOI: 10.1177/0363546519879690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Schwitzguebel AJ, Kolo FC, Tirefort J, Kourhani A, Nowak A, Gremeaux V, Saffarini M, Lädermann A. Efficacy of Platelet-Rich Plasma for the Treatment of Interstitial Supraspinatus Tears: A Double-Blinded, Randomized Controlled Trial. Am J Sports Med 2019; 47:1885-1892. [PMID: 31161947 DOI: 10.1177/0363546519851097] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The benefits of platelet-rich plasma (PRP) for the treatment of rotator cuff tears remain inconclusive, as it is administered either as an adjuvant to surgical repair or as a primary infiltration without targeting the index lesion, which could dilute its effect. PURPOSE To determine whether PRP infiltrations are superior to saline solution infiltrations (placebo) at improving healing, pain, and function when injected under ultrasound guidance within isolated interstitial supraspinatus tears. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS In this single-center, double-blinded, randomized controlled trial, 80 adults with symptomatic isolated interstitial tears of the supraspinatus, confirmed by magnetic resonance arthrography, were randomized to PRP or saline injections. Each patient received 2 injections with a 1-month interval. The primary outcome was the change in lesion volume, calculated on magnetic resonance arthrography, at 7 months. The secondary outcomes were improvements in shoulder pain and the Single Assessment Numerical Evaluation (SANE) score at >12 months. RESULTS Preoperative patient characteristics did not differ between the 2 groups. At 7 months, there were no significant differences between the PRP and control groups in terms of a decrease in lesion size (-0.3 ± 23.6 mm3 vs -8.1 ± 84.7 mm3, respectively; P = .175); reduction of pain on a visual analog scale (VAS) (-2.3 ± 3.0 vs -2.0 ± 3.0, respectively; P = .586); and improvement in SANE (16.7 ± 20.0 vs 14.9 ± 29.0, respectively; P = .650), Constant (8.6 ± 13.0 vs 10.7 ± 19.0, respectively; P = .596), and American Shoulder and Elbow Surgeons (19.5 ± 20.0 vs 21.9 ± 28.0, respectively; P = .665) scores. At >12 months, there were no significant differences between the PRP and control groups in terms of a reduction of pain on a VAS (-3.3 ± 2.6 vs -2.3 ± 3.2, respectively; P = .087) or improvement in the SANE score (24.4 ± 27.5 vs 23.4 ± 24.9, respectively; P = .846). At 19.5 ± 5.3 months, the incidence of adverse effects (pain >48 hours, frozen shoulder, extension of lesion) was significantly higher in the PRP group than the control group (54% vs 26%, respectively; P = .020). CONCLUSION PRP injections within interstitial supraspinatus tears did not improve tendon healing or clinical scores compared with saline injections and were associated with more adverse events. REGISTRATION NCT02672085 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Adrien J Schwitzguebel
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland.,Division of Physical Medicine and Rehabilitation, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Jérôme Tirefort
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | - Abed Kourhani
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Alexandra Nowak
- Division of Physical Medicine and Rehabilitation, Lausanne University Hospital, Lausanne, Switzerland
| | - Vincent Gremeaux
- Division of Physical Medicine and Rehabilitation, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
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Hurley ET, Hannon CP, Pauzenberger L, Fat DL, Moran CJ, Mullett H. Nonoperative Treatment of Rotator Cuff Disease With Platelet-Rich Plasma: A Systematic Review of Randomized Controlled Trials. Arthroscopy 2019; 35:1584-1591. [PMID: 31000394 DOI: 10.1016/j.arthro.2018.10.115] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 10/20/2018] [Accepted: 10/21/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To perform a systematic review of randomized controlled trials on the use of platelet-rich plasma (PRP) for nonoperative treatment of rotator cuff disease. METHODS Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 2 reviewers independently screened the MEDLINE, Embase, and Cochrane Library databases for prospective, randomized controlled trials comparing PRP with a control in the nonoperative treatment of chronic rotator cuff disease for inclusion. Clinical data were extracted and evaluated. The quality of evidence was assessed using The Cochrane Collaboration risk-of-bias tool. RESULTS Five randomized controlled trials met the inclusion criteria, with 108 patients treated with PRP and 106 treated with a control. The mean age was 53.7 years, and 61.6% of patients were female patients. All of the studies found that the groups receiving PRP injections experienced improved clinical outcomes at final follow-up compared with baseline. Two studies found that PRP resulted in improved outcomes, mostly pain scores, compared with a control. One study compared PRP with formal exercise versus a saline solution injection with formal exercise therapy. It showed no difference in clinical outcomes between PRP and a saline solution injection when formal exercise therapy was used. Two other studies reported that PRP alone resulted in inferior outcomes to control groups receiving formal exercise therapy. CONCLUSIONS The currently limited available evidence on PRP for nonoperative treatment of chronic rotator cuff disease suggests that in the short term, PRP injections may not be beneficial. When directly compared with exercise therapy, PRP does not result in superior functional outcomes, pain scores, or range of motion. However, interpretation of this literature is confounded by the lack of reporting of the cytology and characteristics of PRP. LEVEL OF EVIDENCE Level II, systematic review of Level I and II evidence.
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Affiliation(s)
- Eoghan T Hurley
- Sports Surgery Clinic, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland.
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Phadke A, Singh B, Bakti N. Role of platelet rich plasma in rotator cuff tendinopathy- clinical application and review of literature. J Clin Orthop Trauma 2019; 10:244-247. [PMID: 30828186 PMCID: PMC6383120 DOI: 10.1016/j.jcot.2018.10.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 08/25/2018] [Accepted: 10/20/2018] [Indexed: 01/25/2023] Open
Affiliation(s)
- Akshay Phadke
- Canterbury Christchurch University/ Medway Maritime Hospital, Gillingham, Kent, UK
- Corresponding author.
| | - Bijayendra Singh
- Trauma and Orthopaedcics, Medway Maritime Hospital, Gillingham, Kent, UK
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Jo CH, Lee SY, Yoon KS, Oh S, Shin S. Allogenic Pure Platelet-Rich Plasma Therapy for Rotator Cuff Disease: A Bench and Bed Study. Am J Sports Med 2018; 46:3142-3154. [PMID: 30311796 DOI: 10.1177/0363546518800268] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although platelet-rich plasma (PRP) is a popular option for rotator cuff disease, the underlying mechanism of PRP and its clinical indications are unclear. Further, some kinds of PRP might be detrimental to patients. Allogenic PRP prepared through a standardized process and fully characterized could eliminate variations in PRP as well as uncertainties regarding its use in each patient, which could provide clues about its mechanism of action and indications for its use. PURPOSE To assess the effects of pure PRP on tenocytes with or without inflammation in an in vitro study and to evaluate the safety and efficacy of a fully characterized pure PRP injection in patients with rotator cuff disease in a clinical study. STUDY DESIGN Controlled laboratory study and cohort study; Level of evidence, 3. METHODS For the in vitro study, tenocytes were enzymatically isolated and cultured from patients with rotator cuff tear and treated with or without interleukin 1β (IL-1β) and PRP. Gene expression and protein synthesis of pro- and anti-inflammatory cytokines, enzymes and their inhibitors, matrix synthesis, and cell viability were evaluated. For the clinical study, a total of 17 patients with rotator cuff disease received ultrasonography-guided subacromial PRP injection and were followed for 6 months. Pain, range of motion, muscle strength, shoulder function, and overall satisfaction in patients were compared with the results in a propensity score-matched control group who received corticosteroid (triamcinolone acetonide 40 mg). RESULTS PRP induced inflammation in the absence of inflammation and ameliorated inflammation in IL-1β-induced tendinopathic conditions by regulation of cytokines such as IL-1β, cyclooxygenase 2, microsomal prostaglandin E synthase 1, vasoactive intestinal peptide, and downstream matrix metalloproteinases. No general or local adverse events were noted with regard to allogenic PRP injection. Whereas steroid injection showed earlier improvement in some kinds of pain and functional scores, PRP generally showed comparable effects with steroid injection in all clinical outcomes at 6 months. CONCLUSION This study showed that allogenic pure PRP had pleiotropic effects on tenocytes depending on inflammation and that it did not cause adverse events but rather decreased pain and improved shoulder function to a degree comparable with steroid injection in patients with rotator cuff disease. CLINICAL RELEVANCE Allogenic PRP could be a treatment option for rotator cuff disease.
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Affiliation(s)
- Chris Hyunchul Jo
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Dongjak-gu, Seoul, Republic of Korea.,Department of Translational Medicine, Seoul National University College of Medicine, Jongno-gu, Seoul, Republic of Korea
| | - Seung Yeon Lee
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Dongjak-gu, Seoul, Republic of Korea
| | - Kang Sup Yoon
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Dongjak-gu, Seoul, Republic of Korea
| | - Sohee Oh
- Department of Biostatistics, SMG-SNU Boramae Medical Center, Dongjak-gu, Seoul, Republic of Korea
| | - Sue Shin
- Department of Laboratory Medicine, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Dongjak-gu, Seoul, Republic of Korea
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Filardo G, Di Matteo B, Kon E, Merli G, Marcacci M. Platelet-rich plasma in tendon-related disorders: results and indications. Knee Surg Sports Traumatol Arthrosc 2018; 26:1984-1999. [PMID: 27665095 DOI: 10.1007/s00167-016-4261-4] [Citation(s) in RCA: 177] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 08/02/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE Platelet-rich plasma (PRP) is currently the most exploited strategy in the clinical practice to provide a regenerative stimulus for tendon healing. The aim of the present study was to systematically review the available evidence on the treatment of the main tendon disorders where PRP is currently applied. METHODS A systematic review of the literature was performed on the use of PRP as a treatment for tendinopathies focusing on the following sites: Achilles tendon, patellar tendon, rotator cuff tendons, and lateral elbow tendons. The following inclusion criteria for relevant articles were used: clinical trials written in English language up to 21 June 2016 on the use of PRP in the conservative or surgical treatment of the aforementioned tendinopathies. RESULTS The research identified the following clinical trials dealing with the application of PRP in the selected tendons: 19 papers on patellar tendon (6 being RCTs: 4 dealing with PRP conservative application and 2 surgical), 24 papers on Achilles tendon (4 RCTs: 3 conservative and 1 surgical), 29 on lateral elbow tendons (17 RCTs, all conservative), and 32 on rotator cuff (22 RCTs: 18 surgical and 3 conservative). CONCLUSION Patellar tendons seem to benefit from PRP injections, whereas in the Achilles tendon, PRP application is not indicated neither as a conservative approach nor as a surgical augmentation. Lateral elbow tendinopathy showed an improvement in most of the high-level studies, but the lack of proven superiority with respect to the more simple whole-blood injections still questions its use in the clinical practice. With regard to rotator cuff pathology, the vast majority of surgical RCTs documented a lack of beneficial effects, whereas there is still inconclusive evidence concerning its conservative application in rotator cuff disorders. LEVEL OF EVIDENCE Systematic review of level I-IV trials, Level IV.
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Affiliation(s)
- Giuseppe Filardo
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Berardo Di Matteo
- I Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy.
| | - Elizaveta Kon
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Giulia Merli
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Maurilio Marcacci
- Biomechanics and Technology Innovation Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy
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Update on Platelet-rich Plasma for Shoulder and Elbow Tendinopathy. TECHNIQUES IN SHOULDER AND ELBOW SURGERY 2017. [DOI: 10.1097/bte.0000000000000118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Abstract
Chronic pain is an issue encountered by many health care providers in their routine clinical practice. In addition to generalized patient suffering, this condition has significant clinical, psychological, and socioeconomic impact due to its widespread occurrence. The landscape of chronic pain management has been changing rapidly with an array of treatment innovations, better understanding of established therapies, and care coordination across specialties. In this article, we have reviewed emerging new modalities as well as transformation of established therapies by interventional, pharmacologic, rehabilitative, psychological, complimentary, and interdisciplinary approaches.
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Andia I, Maffulli N. Clinical Outcomes of Biologic Treatment for Chronic Tendinopathy. ACTA ACUST UNITED AC 2016. [DOI: 10.1053/j.oto.2015.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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