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

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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.

Significant variability in preparation methods exists, resulting in more than 40 different products.² Some methods centrifuge only once, creating plasma that is separated from red and white blood cells, but without a huge shift in the concentration of platelets; some include white blood cells in the final preparation; and most have differing concentrations of platelets and various growth factors in the end product. Researchers have attempted to classify the various preparations by platelet concentration, inclusion or exclusion of white blood cells, and fibrin content, but no validated system yet exists. Thus, consistency in preparations is lacking.^3,4

PRP is rich not only in platelets, but also in a multitude of other growth factors. It is thought to improve healing by enhancing the body’s natural regenerative processes at the tissue level. In OA, for example, a complex balance of destructive and reparative processes is at play; PRP is thought to tip the body’s response in favor of regeneration over destruction. Similarly, chronic tendinopathy involves a process of destruction, reaction, healing, and degeneration; intervening at the correct point in this pathway with a boost to healing may help the body repair an otherwise diseased tendon.³

What does the evidence show?

Overall, basic science and preclinical research support “the promise” of PRP(strength of recommendation [SOR]: A).⁵ However, patient-centered evidence is lacking, and tremendous variability exists between studies, not only in terms of PRP preparation, but also with regard to:

Protocol—Was ultrasound guidance used? Did the injection include needling of the tendon? What post-injection rehabilitation was followed?
Patient population—What treatments were tried in the past? How chronic or severe was the problem?
Study design—What was the comparison group? How were pain and function measured? Most studies have been small in size and have included various treatment modalities in addition to the PRP injection (most often PT).

Knee OA: PRP may provide short-term benefit, especially in younger patients

Researchers have conducted a number of studies evaluating PRP for knee OA.^6-12 Most have compared PRP to HA—another intra-articular injection that is plagued by mixed, limited, and poor-quality evidence. These trials have had varied results and do not consistently support PRP as superior to HA.

The most well-designed study to date demonstrated that PRP was superior to saline and as effective as HA.¹¹ In addition, the researchers found that a series of 3 PRP injections was superior to 3 injections of HA or only one injection of PRP.

One small randomized controlled trial (RCT) compared PRP injections to saline and found that PRP improved pain and function better than placebo at 6 weeks, 3 months, and 6 months; results appeared to deteriorate after that time period.⁶ Also, the findings suggested that PRP delivered the strongest benefit in younger patients who had less advanced OA.

In addition, a recent systematic review found short-term improvements in functional outcomes in patients treated with PRP injections vs those treated with HA injections and those treated with placebo.¹²

Basic science and preclinical research support “the promise” of platelet-rich plasma, but patient-centered evidence is lacking, and tremendous variability exists between studies.

But before experts can make any conclusive recommendations regarding the use of PRP for knee OA, standardized studies with larger numbers of participants and rigorous methodology must be designed. Notably, no evidence exists of significant harm resulting from PRP injection for knee OA. Therefore, given the mixed evidence in terms of efficacy, there may be a potential benefit to treatment with little negative consequence.

In 2013, the American Academy of Orthopaedic Surgeons (AAOS) stated that they were unable to recommend for or against PRP injection for patients with symptomatic OA of the knee because the evidence was inconclusive.¹³ At the same time, the AAOS was unable to recommend for or against corticosteroid injections, manual therapy, or bracing for knee OA, and recommended against HA injections.¹³ Recently, however, the American Medical Society for Sports Medicine (AMSSM) recommended that HA be used in appropriate patients with knee OA.¹⁴

Such disagreement indicates that evidence is lacking for many modalities employed in the management of knee OA, including the injection of corticosteroids, which is a frequent and generally accepted treatment. Compounding matters is that many of the original studies testing the efficacy of PRP injection in knee OA used HA injections as the comparison, and there is no agreement between AAOS and AMSSM as to its usefulness. Thus, the validity of using HA as a control is suspect.

Tendinopathies: PRP may have benefit, but more research is needed

A number of meta-analyses and systematic review articles have combined the results of studies involving PRP treatment for various tendinopathies.^3,15-17 While most found that PRP may have a benefit (although not long-lasting) and may be of use in attempts to avoid surgery or to return to a desired activity, all reported that more rigorous studies with standardized methodologies must be conducted before PRP can be conclusively recommended for any anatomic site.