Is platelet-rich plasma right for your patient?

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Applied Evidence

Is platelet-rich plasma right for your patient?

J Fam Pract. 2016 May;65(5):319-321,326-328

Jordan White, MD, MPH

Jeffrey Manning, MD

Many pro athletes claim that platelet-rich plasma has improved their performance and saved their careers. But is it right for your patients? And if so, which ones?

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References

1. Washington Health Policy Fellows of the American Academy of Orthopaedic Surgeons. Musculoskeletal education in medical schools: are we making the cut? Available at: http://www.aaos.org/news/bulletin/marapr07/reimbursement2.asp. Accessed September 20, 2015.

2. Hsu WK, Mishra A, Rodeo S, et al. Platelet-rich plasma in orthopaedic applications: evidence-based recommendations for treatment. J Am Acad Orthop Surg. 2013;21:739-748.

3. Harmon KG, Rao AL. The use of platelet-rich plasma in the nonsurgical management of sports injuries: hype or hope? Hematology Am Soc Hematol Educ Program. 2013;2013:620-626.

4. Mautner K, Malanga GA, Smith J, et al. A call for a standard classification system for future biologic research: the rationale for new PRP nomenclature. PM R. 2015;7:S53-S59.

5. Hannafin JA, Arnoczky SP, Fu FH, et al. Platelet-rich plasma: Clarifying the issues. AAOS Now. September 2010. Available at: http://www.aaos.org/AAOSNow/2010/Sep/clinical/clinical1/?ssopc=1. Accessed April 8, 2016.

6. Patel S, Dhillon MS, Aggarwal S, et al. Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis: a prospective, double-blind, randomized trial. Am J Sports Med. 2013;41:356-364.

7. Filardo G, Di Matteo B, Di Martino A. Platelet-rich plasma intra-articular knee injections show no superiority versus viscosupplementation: A Randomized Controlled Trial. Am J Sports Med. 2015;43:1575-1582.

8. Forogh B, Mianehsaz E, Shoaee S, et al. Effect of single injection of platelet-rich plasma in comparison with corticosteroid on knee osteoarthritis: a double-blind randomized clinical trial. J Sports Med Phys Fitness. July 14, 2015. [Epub ahead of print]

9. Laudy AB, Bakker EW, Rekers M, et al. Efficacy of platelet-rich plasma injections in osteoarthritis of the knee: a systematic review and meta-analysis. Br J Sports Med. 2015;49:657-672.

10. Campbell KA, Saltzman BM, Mascarenhas R, et al. Does intra-articular platelet-rich plasma injection provide clinically superior outcomes compared with other therapies in the treatment of knee osteoarthritis? a systematic review of overlapping meta-analyses. Arthroscopy. 2015;31:2213-2221.

11. Görmeli G, Görmeli CA, Ataoglu B, et al. Multiple PRP injections are more effective than single injections and hyaluronic acid in knees with early osteoarthritis: a randomized, double-blind, placebo-controlled trial. Knee Surg Sports Traumatol Arthrosc. August 2, 2015. [Epub ahead of print]

12. Kanchanatawan W, Arirachakaran A, Chaijenkij K, et al. Short-term outcomes of platelet-rich plasma injection treatment of osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc. September 19, 2015. [Epub ahead of print]

13. American Academy of Orthopaedic Surgeons. Treatment of Osteoarthritis of the Knee: Evidence-Based Guideline. 2nd edition. Adopted May 18, 2013. Available at: http://www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf. Accessed March 11, 2016.

14. Trojian TH, Concoff AL, Joy SM, et al. AMSSM Scientific Statement Concerning Viscosupplementation Injections for Knee Osteoarthritis: Importance for Individual Patient Outcomes. Clin J Sport Med. 2016;26:1-11.

15. Moraes VY, Lenza M, Tamaoki MJ, et al. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2014;4:CD010071.

16. Nourissat G, Ornetti P, Berenbaum F, et al. Does platelet-rich plasma deserve a role in the treatment of tendinopathy? Joint Bone Spine. 2015;82;230-234.

17. Andia I, Latorre PM, Gomez MC, et al. Platelet-rich plasma in the conservative treatment of tendinopathy: a systematic review and meta-analysis of controlled studies. Br Med Bull. 2014;110:99-115.

18. Creaney L, Wallace A, Curtis M, et al. Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections. Br J Sports Med. 2011;45:966-971.

19. Krogh TP, Fredberg U, Stengaard-Pedersen K, et al. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013;41:625-635.

20. Thanasas C, Papadimitriou G, Charalambidis C, et al. Platelet-rich plasma versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis: a randomized controlled clinical trial. Am J Sports Med. 2011;39:2130-2134.

21. Peerbooms JC, Sluimer J, Bruijn DJ, et al. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med. 2010;38:255-262.

22. Arirachakaran A, Sukthuayat A, Sisayanarane T, et al. Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-analysis. J Orthop Traumatol. September 11, 2015. [Epub ahead of print]

23. Vetrano M, Castorina A, Vulpiani MC, et al. Platelet-rich plasma versus focused shock waves in the treatment of jumper’s knee in athletes. Am J Sports Med. 2013;41:795-803.

24. Dragoo JL, Wasterlain AS, Braun HJ, et al. Platelet-rich plasma as a treatment for patellar tendinopathy: a double-blind, randomized controlled trial. Am J Sports Med. 2014;42:610-618.

25. de Vos RJ, Weir A, van Schie HT, et al. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA. 2010;303:144-149.

26. Beyer R, Kongsgaard M, Hougs Kjæ B, et al. Heavy slow resistance versus eccentric training as treatment for Achilles tendinopathy: a randomized controlled trial. Am J Sports Med. 2015;43:1704-1711.

27. Beitzel K, Allen D, Apostolakos J, et al. US definitions, current use, and FDA stance on use of platelet-rich plasma in sports medicine. J Knee Surg. 2015;28:29-34.27.

PRACTICE RECOMMENDATIONS

› Inform patients with knee osteoarthritis that although evidence is limited, platelet-rich plasma (PRP) injections may improve pain and function in the short-term. B
› Advise patients with elbow epicondylitis that PRP injections may improve pain and function slightly more than corticosteroid injections in the short-term. B
› Counsel patients that PRP has minimal risks; however, larger studies are needed to more fully assess whether harms exist. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE 1 › Ms. T is an otherwise healthy 76 year old with a history of severe osteoarthritis (OA) in her right knee. She has participated in multiple rounds of physical therapy (PT) over the last 3 years. During the past year, she received 2 intra-articular corticosteroid injections, each of which provided only 3 to 4 weeks of pain relief, and one hyaluronic acid (HA) injection, which provided no benefit whatsoever.

Today, she describes her right knee pain as an 8 out of 10 and is frustrated by her lack of symptom relief. She was planning to have a total knee replacement and is a good surgical candidate, but recently found an article regarding platelet-rich plasma (PRP) injections for knee OA. She wants your opinion as to whether she should try this approach or proceed with surgery.

CASE 2 › Mr. H is a 44-year-old, right-handed dentist who has been suffering from right lateral epicondylitis for the past year. Although he has undergone PT and has been performing exercises at home since his symptoms began, he has not noticed a significant improvement. In the last 5 months, he has been out of work a total of 8 weeks due to the pain. He received one corticosteroid injection last month, which provided no improvement in symptoms. He is not interested in surgery, as he does not want to be out of work for a prolonged period of time.

He reports that one of his friends recently received a PRP injection for lateral epicondylitis and now feels great. He is aware that PRP injections are not covered by his health insurance and says he is willing to pay out of pocket if the treatment works. He wants to know if you recommend this course of action for his elbow pain.

How would you counsel each of these patients about the use of PRP injections for pain relief from their respective orthopedic conditions?

Musculoskeletal symptoms account for 10% to 28% of patients’ complaints to primary care physicians annually.¹ Treatment of both chronic tendinopathies and knee OA—2 of the most common causes of these complaints—typically follows a stepwise approach, beginning with anti-inflammatory and pain medications in addition to PT. Patients who fail to respond to these interventions are often treated with corticosteroid injections, and, in the case of knee OA, viscosupplementation (ie, HA injections) and braces. If these therapies fail, patients are often forced to choose between an invasive surgical procedure or continued pain and limited function.

Platelet-rich plasma is thought to tip the body’s response in favor of regeneration over destruction.

A number of physicians specializing in musculoskeletal medicine have turned to prolotherapy—specifically, dextrose prolotherapy (see “Prolotherapy: Can it help your patient?” J Fam Pract. 2015;64:763-768) and platelet-rich plasma (PRP) therapy—as an alternative treatment for chronic musculoskeletal conditions.

PRP has been used to enhance surgical healing and to treat muscle strains and chondropathies. It drew a great deal of attention in the media when it was used by such high-profile professional athletes as Tiger Woods and Kobe Bryant.

Although PRP therapy is not commonly reimbursed by health insurance companies because of a lack of large, definitive studies supporting its effectiveness, patients are paying anywhere from a few hundred to a few thousand dollars out of pocket for it. They’re doing so in the hope that it will treat their chronic musculoskeletal disorders or at least delay surgical procedures.

But what can these patients reasonably expect from this therapy?

The following review of the evidence for PRP in the treatment of knee OA and tendinopathies (including elbow epicondylitis, patellar tendinitis, and Achilles tendinitis) will help you counsel patients on its appropriate use.

What is PRP?

PRP is defined as a sample of autologous blood with concentrations of platelets above baseline values.² It is made through a one- or 2-stage centrifugation process in which the liquid and solid components of whole blood are separated, and then the liquid components are further separated into portions that are platelet-rich and platelet-poor.