Comparative Efficacy of Platelet Rich Plasma Injection, Corticosteroid Injection and Ultrasonic Therapy in the Treatment of Periarthritis Shoulder

Injection of autologous conditioned plasma combined with a collagen scaffold may improve the clinical outcome in shoulder impingement syndrome: a prospective study

BACKGROUND

Shoulder impingement syndrome (SIS) is one of the most common diseases of the shoulder and can be addressed with various therapeutic concepts. Orthobiological agents such as platelet rich plasma with a low side effect rate gain importance in the conservative treatment of SIS. Currently, the knowledge about success rate influencing factors, such as the growth factors (GF) concentration or acromion type, is limited. The aim of this study was to analyze the clinical outcome in the therapy of external SIS using autologous conditioned plasma combined with recombinant human collagen scaffold (ACP/STR) injection in comparison with a corticosteroid-local anesthetic (CSA) injection. Additionally, the influence of potential limiting factors such as GF concentration, age and acromial morphology was proved.

MATERIALS AND METHODS

This prospective pseudo-randomized trial recruited 58 patients with external SIS who received an ultrasound-guided subacromial injection either an ACP/STR or a CSA followed by physical therapy. Follow-up (FU) was performed at 6 weeks, 3 and 6 months. The outcome was assessed with Constant-Murley score, disability of arm, shoulder and hand score and simple shoulder test. The concentration of GF was measured using ELISA.

RESULTS

During the FU, the improvement of outcome measures was observed with no differences between both groups. Shoulder force was significantly increased in the ACP/STR group (p < 0.01). We found no correlation between the amount of GF and age or gender in the ACP/STR patients. An acromion Bigliani type III predisposes for therapy failure (p < 0.001, OR = 56) in both treatment groups.

CONCLUSIONS

Patients with SIS benefit regarding to PROMs after both ACP/STR and CSA injection and physical therapy. Patients who received ACP/STR obtained superior improvement in force. The quantity of GF did not vary depending on the age, so that ACP/STR can be a treatment option for SIS in elderly patients with multimorbidity. The presence of an acromion type III seems to be a predictive factor for limited effectivity of injections in the clinical management of SIS.

Platelet-Rich Plasma for Adhesive Capsulitis: A Systematic Review

Adhesive capsulitis (AC) is a common cause of shoulder pain seen in 3%-5% of the population. Platelet-rich plasma (PRP) is platelet-rich blood with pro-inflammatory and anti-inflammatory properties that has been proposed as a treatment option for patients with AC. The purpose of this study was to analyze outcomes of range of motion (ROM) and subjective outcomes, including the visual analog scale (VAS), disability of arm, shoulder, and hand (DASH), and shoulder pain and disability index (SPADI) scores. PubMed, Embase, and Cochrane databases were searched, and manuscripts were screened using defined preferred reporting items for systematic reviews and meta-analyses (PRISMA) criteria. Two reviewers independently screened articles for inclusion/exclusion using PICOS criteria and extracted data regarding ROM and subjective outcome scores. Nineteen total articles were included. Eleven of the 19 studies recorded ROM as a dependent variable. All articles reported improved ROM with PRP injection when compared to baseline. When recording degrees of shoulder ROM in different planes at the latest follow-up, there were a total of 67 comparative data points for PRP vs. control. Of the 67 comparisons, 62 (93%) had a larger final ROM in the PRP group. VAS scores were reported in 16 of the 19 studies, DASH scores were reported in eight of the 19 articles, and SPADI scores were reported in seven of the 19 articles. VAS, DASH, and SPADI scores were all superior in the PRP group compared to the control. Two studies reported the same final VAS score, but the PRP groups had a larger overall improvement. Of the studies that reported objective ROM outcomes, the PRP group had greater ROM at the longest follow-up compared to control in the vast majority of comparisons. For the studies that reported subjective outcomes, all patients that received PRP had a decrease in VAS pain scores and an improvement in DASH and SPADI questionnaires.

Allogenic Platelet-Rich Plasma for the Treatment of Adhesive Capsulitis

Adhesive capsulitis (AC) is a common shoulder disorder leading to pain and restricted range of motion (ROM) and affects the patient's activities of daily living (ADL) and overall quality of life (QoL). Conservative therapies are prioritized, resorting to surgical intervention only when necessary. Unfortunately, these modalities have limitations and do not address the underlying pathological cause of AC. The use of autologous biologics, such as platelet-rich plasma (PRP), has evolved and shown promise for managing musculoskeletal (MSK) injuries, including AC. However, subpar functional outcomes have led clinicians to question the long-term efficacy of autologous PRP. To circumvent this, the possibility of utilizing a standardized and well-characterized allogenic PRP for AC has been explored. In this manuscript, we qualitatively present in vitro, pre-clinical, clinical, and ongoing studies investigating the varied applications of allogenic PRP for the management of AC. The results demonstrated that allogenic PRP acts in a pleiotropic manner and decreases pro-inflammatory cytokines only in the inflammatory condition. In addition, the administration of allogenic PRP is safe and potentially efficacious, in terms of reducing pain and improving range of motion, shoulder strength, and function, in non-surgical management of AC. Nonetheless, more pre-clinical studies and adequately powered, multicenter, prospective, non-randomized, and randomized controlled trials with longer follow-up are warranted to further establish the safety and efficacy of allogenic PRP and justify its routine clinical use.

Comparing the Efficacy of Intra-articular Platelet-Rich Plasma and Corticosteroid Injections in the Management of Frozen Shoulder: A Randomized Controlled Trial

Introduction Periarthritis of the shoulder, or frozen shoulder (FS), is a common, painful, and disabling condition with varied treatment strategies. Intra-articular (IA) corticosteroid (CS) injections are a popular treatment option, but their efficacy is often temporary. Platelet-rich plasma (PRP) has emerged as an alternative therapy for adhesive capsulitis, but the literature on its effectiveness is limited. This study aimed to compare the efficacy of IA PRP and CS injections in managing FS. Methods In this prospective, randomized study, 68 patients who met the inclusion criteria were enrolled and randomized using a computer-generated table into two groups: Group 1 (IA PRP) received 4 ml PRP, and Group 2 (IA CS) received 2 ml (80 mg) of methylprednisolone acetate mixed with 2 ml normal saline (for a total of 4 ml) as a CS injection in the IA area of the shoulder. Outcome measures included pain; shoulder range of motion (ROM); the condensed version of the disabling conditions of the arm, shoulder, and hand (QuickDASH) score; and the shoulder pain and disability index (SPADI) score. Participants were monitored via follow-up for 24 weeks, with pain and function assessed at each evaluation using the visual analog scale (VAS) score, the SPADI score, and the QuickDASH score. Results The IA PRP injections demonstrated better long-term outcomes than the IA CS injections, significantly improving pain, shoulder ROM, and daily activity performance. After 24 weeks, the mean VAS score in the PRP and methylprednisolone acetate groups was 1.00 (1.0 to 1.0) and 2.00 (2.0 to 2.0), respectively (P≤0.001). The mean QuickDASH score was 41.83 ± 6.33 in the PRP group and 48.76 ± 5.08 in the methylprednisolone acetate group (P≤0.001). The mean SPADI score was 53.32 ± 7.49 in the PRP group and 59.24 ± 5.80 in the methylprednisolone acetate group (P≤0.001), indicating a significant improvement in the PRP group's pain and disability scores after 24 weeks. The rate of complications was similar between the two groups. Conclusions Our findings suggest that IA PRP injections provide better long-term results than IA CS injections for managing FS. Platelet-rich plasma can be used as a treatment modality for better outcomes, particularly when the patient is contraindicated or refuses CS treatment. Further research is needed to evaluate the efficacy of these treatment modalities at different stages of FS and explore the potential benefits of ultrasound-guided injections.

Comparison of the Efficacy of Platelet-Rich Plasma (PRP) and Local Corticosteroid Injection in Periarthritis Shoulder: A Prospective, Randomized, Open, Blinded End-Point (PROBE) Study

Background

Periarthritis or frozen shoulder, also called adhesive capsulitis, is characterized by stiffness and pain along with gradual loss of active and passive movement in the glenohumeral joint. More than 2-5% of the population suffers from periarthritis with a higher incidence in the age group of 40-60 years. The various treatment modalities used for its management include simple physiotherapy, short-wave therapy, ultrasonic therapy, transcutaneous electrical nerve stimulation, hydrotherapy, analgesics, intra-articular injections, manipulation under general anesthesia (MUA), and surgical management. The application of intra-articular steroid injection has been a common and efficacious option in rapidly diminishing shoulder pain and disability. Some recent studies reported a better outcome using platelet-rich plasma (PRP) injections in frozen shoulder cases. Hence, this randomized controlled trial was conducted to compare the efficacy of intra-articular injections of PRP and triamcinolone in patients of shoulder periarthritis in a population from the eastern region of India

Methodology

A total of 60 patients with periarthritis shoulder were allocated into two groups after randomization. Group A received 2 mL autologous PRP, and Group B received 2 mL of triamcinolone (40 mg/mL) intra-articular injection. Patients were followed up on the 4th week, 12th week, and 24th week. The assessment of pain and function using the visual analog scale (VAS) score and the Disabilities of Arm, Shoulder, and Hand (DASH) score, respectively, was done at each follow-up. The primary analyses of both primary and secondary outcomes were conducted in the intention-to-treat (ITT) population. SPSS version 24 (IBM Corp., Armonk, NY, USA) was used for data analysis.

Results

The mean VAS score in the PRP and triamcinolone groups was 14.33 ± 3.79 and 31.63 ± 7.62, respectively (p = 0.0001) after 24 weeks. The mean DASH score in the PRP and triamcinolone groups was 18.08 ± 8.08 and 31.76 ± 3.63, respectively (p = 0.0001), which shows significant improvement in both pain and disability scores in the PRP group after 24 weeks.

Conclusions

The triamcinolone group showed better short-term outcomes whereas PRP showed better long-term outcomes in reducing pain and disability scores in terms of VAS and DASH scores.

The Effectiveness of Ultrasound Deep Heat Therapy for Adhesive Capsulitis: A Systematic Review and Meta-Analysis

Background: Adhesive capsulitis occurs with synovial inflammation and capsular fibrosis in the glenohumeral joint, leading to restriction of joint motion and pain. Heat therapy modalities, which aim at modifying dense collagenous tissues are commonly practiced interventions for patients with adhesive capsulitis; however, the effectiveness of ultrasound deep heat therapy (UST) on adhesive capsulitis is still unclear. Purpose: This systematic review and meta-analysis study was conducted to evaluate the effects of UST on the improvement of pain and glenohumeral joint function in adhesive capsulitis compared to (1) no treatment or placebo, and (2) any other therapeutic modalities. Methods: A literature search was carried out in January 2021 in Cochrane Central Register of Controlled Trials, PubMed, EMBASE, PEDro, Web of Science, and Google Scholar. The main outcomes of interest were self-reported pain scores, disability scores, and the range of motion. This study was conducted based on the guidelines of the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) protocols, using random-effects models. Results: Seven studies were included in the systematic review with five studies forming the basis for meta-analyses. The effects of UST in patients with adhesive capsulitis were compared with placebo, shockwave therapy, corticosteroid injection, platelet-rich plasma injection, or cryotherapy. The results indicated that UST significantly improved pain scores when performed together with exercise and/or other physical modalities compared to placebo; however, whether UST provides benefits for the improvement of disability and/or the range of motion was uncertain in the present results. Conclusions: The present findings suggest that UST as a co-intervention combined with other physical modalities is an effective means of improving the overall pain in patients with adhesive capsulitis.

Platelet-rich plasma as a potential prophylactic measure against frozen shoulder in an in vivo shoulder contracture model

INTRODUCTION

Frozen shoulder (adhesive capsulitis) is a common painful and functionally-limiting disease affecting around 2% of the population. So far, therapeutic options are limited and often unsatisfactory. Platelet-rich plasma (PRP) has been used as a treatment option in other orthopedic diseases since it contains growth factors that stimulate tissue repair. So far, the effect of PRP on frozen shoulder lacks evidence. We hypothesized that PRP may be valuable in the prophylaxis and treatment of secondary frozen shoulder due to capsular remodeling.

MATERIALS AND METHODS

An experimental study of an in vivo frozen shoulder model was conducted. Twenty Sprague-Dawley rats underwent surgery in which the body of the scapula was connected to the humerus with a high-strength suture. Two groups of 8 weeks survival time were allocated; a treatment group with one intraoperative injection of PRP into the glenohumeral joint (n = 10) and a control group without PRP (n = 10). The primary outcome was the structural change in the posterior synovial membrane of the posterior and inferior part of the glenohumeral joint using a semi-quantitative grading from 0 (lowest) to 3 (highest).

RESULTS

The posterior synovial membrane structural changes were significantly lower in the PRP group (median = 1 [interquartile range (IQR) = 0-1]) compared to controls (median = 2 [IQR = 1-3]) (p = 0.028). There were no differences for the remaining synovial membrane changes and fibrous capsule responses between groups.

CONCLUSIONS

In this in vivo shoulder contracture model, PRP injections seem to reduce the histological severity grade of some parts (i.e., posterior synovial membrane changes) of the secondary frozen shoulder without causing any side effects. It may be considered to investigate this effect further in future studies as a potential prophylaxis of secondary frozen shoulder (e.g., in operated or immobilized shoulders) or as a treatment option for patients with frozen shoulder in the early stage.

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

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.

The benefit of platelet-rich plasma injection over institution-based physical therapy program in adhesive capsulitis patients with diabetes mellitus: prospective observational cohort study

Background

The objective of this study was to compare the efficacy of platelet-rich plasma (PRP) injection with an institution-based physical therapy (PT) program for adhesive capsulitis (AC) of the shoulder in patients with diabetes mellitus (DM).

Methods

A total of seventy diabetic patients with AC of the shoulder for <6 months were assigned to two groups: PRP group and PT group. In the PRP group, 35 patients were administered a single shot of PRP (4 mL) into the glenohumeral joint. In the PT group, 35 patients were given institution-based PT that included 10 30-minute sessions of planned PT over a 2-week period. After the interventions, all patients were prospectively followed for 12 weeks. Intensity of shoulder pain, function, and range of motion were assessed at baseline and then at 3, 6, and 12 weeks.

Results

Thirty-three patients in the PRP group and 32 in the PT group completed the 12-week study. At 12 weeks, patients who received PRP injections showed greater improvement in shoulder pain (p<0.001) than those recruited to the PT group. In the range of motion and shoulder function activities, patients in the PRP group showed significant improvement compared with the institution-based PT group (p<0.001). No significant complications were reported from any groups.

Conclusions

In a diabetic population, PRP injections significantly improved shoulder pain and function compared with an institution-based PT program for shoulder AC. Additionally, it is a safe and well-tolerated method for AC management for diabetic patients.

Scapular stabilization exercise based on the type of scapular dyskinesis versus traditional rehabilitation training in the treatment of periarthritis of the shoulder: study protocol for a randomized controlled trial

BACKGROUND

Periarthritis of the shoulder is a common disease leading to dysfunction of the shoulder joint and have a significant impact on patients' daily life. Evidence shows that there is a close relationship between scapular dyskinesis (SD) and shoulder diseases. Scapular stabilization exercise has been proved to be efficacious in relieving pain and improving function. However, there is no targeted exercise based on the type of scapular dyskinesis. This study will investigate the potential of scapular stabilization exercise based on the type of scapular dyskinesis in treating periarthritis of the shoulder.

METHODS

This study is a prospective, randomized controlled, parallel-group trial, intending to recruit 90 patients diagnosed with periarthritis of the shoulder. Patients will receive scapular stabilization exercise training based on the type of scapular dyskinesis or receive traditional rehabilitation training conducted for 30 min, once a day, for 6 weeks. The primary outcome is Constant-Murley score (CMS), and other outcomes include pain degree, range of motion (ROM), type of scapular dyskinesis, scapula position, and patients' satisfaction with shoulder function. Assessments will be performed at baseline, 2-, 4- and 6-week treatment, and at the 6-week follow-up after the end of treatment.

DISCUSSION

This study will be the first study to investigate the clinical efficacy of scapular stabilization exercise based on the type of scapular dyskinesis in patients with periarthritis of the shoulder. The results may provide evidence of the effect of targeted scapular stabilization exercise in improving shoulder function and correcting scapular dyskinesis, and provide valuable information for future research.

TRIAL REGISTRATION

This study had been registered in the Chinese Clinical Trials Registry. Registration number: ChiCTR2100044332 at March 14, 2021.

Effect of Minimally Invasive Pain Intervention in Frozen Shoulder Patients: A Cross-Sectional Study

Background:

Adhesive capsulitis or frozen shoulder (FS) is the second most common disorder accounts for 15%–30% shoulder pain and functional disability. Suprascapular nerve (SSN) interventions with corticosteroid alone have shown limited duration efficacy, adding pulsed radiofrequency (PRF) provides long-term relief.

Aims and Objective:

We aimed to analyze the efficacy of SSN intervention on pain relief and range of mobility in patients with FS.

Settings and Design:

This is a cross-sectional study of 37 patients of FS who underwent SSN interventions in a dedicated pain medicine unit of the department of anesthesiology.

Materials and Methods:

Thirty-seven patients, who underwent SSN interventions for FS and followed for 6 months, were included in this study. Pain (Visual Analog Scale [VAS]), range of motion (ROM) (17), and Oxford 12 point Shoulder Score (OSS) for functional outcomes were recorded. In the final analysis, two subsets of patients who underwent SSN steroid injection or SSN PRF plus steroid were found and compared using Student's t-test paired and independent with P < 0.05 considered significant at 95% confidence interval.

Results:

The patient population was demographically comparable. Mean VAS score and ROM improved at 1, 3, and 6 months to statistically significant. On comparing the subgroups, the VAS score and OSS in both the SI and PRF groups were significantly improved, but the PRF group showed highly significant improvement, showing better and sustained improvement in the PRF group.

Conclusion:

PRF with steroid injection of the SSN provides better and long-lasting relief from pain and improved mobility in FS patients in comparison to steroid alone.

Biologics in shoulder and elbow pathology

In recent years, orthobiologics have been of increasing clinical interest in the treatment of shoulder and elbow pathology. In some conditions, such as rotator cuff injury and lateral epicondylitis, there have been high-quality trials that support the use of platelet-rich plasma in reducing pain, restoring functionality, and improving clinical outcomes. However, as the numbers of both cellular-based biologics and the conditions being augmented by biologics continue to expand, there is a substantial need for high-quality investigations to support their routine use in most shoulder and elbow conditions. The purpose of this review is to summarize the current evidence of orthobiologics in the management of shoulder and elbow injury, as nonoperative treatment and as augments to operative treatment.

Intra-articular steroid for adhesive capsulitis: does hydrodilatation give any additional benefit? A randomized control trial

OBJECTIVES

To assess the benefit offered by capsular hydrodilatation in addition to intra-articular steroid injections in cases of adhesive capsulitis, assess outcomes in diabetic patients with capsular hydrodilatation as compared to non-diabetics and correlate duration of symptoms with outcome based on the type of intervention given.

MATERIALS AND METHODS

This prospective double-blinded randomized control trial included patients presenting with clinical features of adhesive capsulitis with no evidence of rotator cuff pathology and randomized them into two groups-intra-articular steroid with hydrodilatation (distension group) and only intra-articular steroid (non-distension group) with intervention being performed as per the group allotted. Primary outcome measure was Shoulder Pain and Disability Index (SPADI) scores which were taken pre-intervention, at 1.5, 3 and 6 months post-intervention, which were assessed by generalized linear model statistics and Pearson correlation.

RESULTS

Although there was statistically significant drop in SPADI in both groups over time [F(1.9, 137.6) = 112.2; p < 0.001], mean difference in SPADI between the 2 groups was not statistically significant (1.53; CI:-3.7 to 6.8; p = 0.56). There was no significant difference between both groups among diabetics [F(1,38) = 0.04; p = 0.95] and no significant difference between diabetic and non-diabetic patients who received hydrodilatation [F(1.8, 60) = 2.26; p = 0.12]. There was no significant correlation between the reduction in SPADI scores and duration of symptoms in any subset of the study population.

CONCLUSION

Shoulder joint hydrodilatation offered no additional benefit compared to intra-articular steroid injections for shoulder adhesive capsulitis. Outcome for diabetics and non-diabetics were similar and there was no correlation between duration of symptoms and outcome.

Therapeutic ultrasound potentiates the anti-nociceptive and anti-inflammatory effects of curcumin to postoperative pain via Sirt1/NF-κB signaling pathway

Background: Postoperative pain has well defined and is perceived by patients as one of the most obnoxious aspects of surgical pain. The aim of this study was to determine whether the combination of Therapeutic ultrasound (TUS) and Curcumin (CUR) resulted in an enhancement of their pain relieving activities in a rat model of postoperative pain. Methods: We explored the effect of these treatment and their interaction with signal transduction pathways involved in inflammatory. In this study, TUS and CUR alone or in combination were administered prior to or simultaneously with or after the incisional surgery. Results: At the start time of administration, we observed that the TUS plus CUR treatment reduced the mean paw withdrawal threshold more efficiently than CUR alone. Then we demonstrated that TUS potentiates the antinociceptive effect of CUR in a rat model of chronic postoperative pain and that the combination could facilitate the recovery of surgical pain. However, preventive value was not statistically significant when the treatments were given prior to the incisional surgery. We provide evidence that TUS plus CUR administrations were safe and significantly reduced the ED50 compared to treatment with the single CUR treatment in rats. TUS plus CUR administrations decreases incisional surgery induced activation of inflammatory cells and down-regulation of chemokines and proinflammatory cytokines, MCP-1, MIP-1α, IL-1β, and TNF-α through regulating Sirt1/NF-κB signaling pathway. Conclusions: Taken together, our results indicate that the combinations of TUS and CUR can be more effective in the anti-nociceptive effects than the treatment with CUR alone.