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.

Elbow epicondylitis (tennis elbow). The majority of tendinopathy studies have examined the effect of PRP on tennis elbow, although given the small study numbers (N=20-100), high risks of bias, and very different comparison groups, the data are extremely limited. Of the 4 randomized studies,^18-21 2 compared different PRP preparations to whole blood,^18,20one compared PRP to both saline and corticosteroid,¹⁹ and one compared PRP to corticosteroid alone.²¹

The studies comparing PRP to whole blood found similar outcomes at most time points.^18,20These studies were of extremely poor quality, and other review articles have defined whole blood as a type of PRP, so this comparison was somewhat inappropriate. One recently published meta-analysis, which included 10 studies comparing either PRP or whole blood to corticosteroid, found that PRP improved pain more than a corticosteroid.²²

The one study that included a comparison of PRP to placebo (saline) suffered from a high dropout rate, and the authors were not able to analyze the primary outcome data. At 3 months, the participants remaining in each group (PRP, saline, or corticosteroid) had similar pain and disability scores.¹⁹ Although the steroid group had improved from baseline at one month, there was no difference between the steroid group and placebo group at 3 months. The PRP group did not differ from the placebo group at any time point.

The study comparing PRP to corticosteroid alone found that PRP’s effects on pain and function exceeded those of the steroid. Specifically, the steroid group initially improved and then worsened, ending the study near their baseline pain and function scores.²¹ The PRP group, on the other hand, showed slow improvement throughout, ending the study with less pain and disability than when they started.

There is no evidence of significant harms associated with platelet-rich plasma treatment, but studies have lacked the power to detect rare but serious problems.

Patellar tendinitis (jumper’s knee). The majority of studies examining the effect of PRP on patellar tendinitis are non-randomized, non-comparative studies. Of the 2 small RCTs that were conducted, one compared PRP to extracorporeal shockwave therapy (ESWT),²³ and the other to dry needling.²⁴

In the ESWT study, there was a slight improvement in pain and function in the PRP group relative to the ESWT group at 6 and 12 months. In the other study, although the PRP group showed an improvement in recovery at 12 weeks relative to the dry needling group, there was no difference between such outcomes as pain and activity in the 2 groups at 26 weeks.

Worth noting here is that like the studies done on OA patients, the research involving patellar tendinitis also used comparative interventions (ESWT and dry needling) that lack high-quality evidence for their use. So whether these were appropriate comparisons is debatable.

Achilles tendinitis. Only one RCT (N=54) has evaluated PRP for the treatment of Achilles tendinitis.²⁵ This study, which compared PRP to saline, excluded patients who had previously completed a course of PT, yet both study groups participated in PT during the study. Although the trial found no difference between groups at any time point (both showed improvement), it was underpowered to detect any difference (positive or negative) between groups, given that most participants likely would have improved with PT anyway.²⁶

PRP has few harms or adverse effects

Most individual studies involving PRP have not reported on harms or side effects; the studies that have reported on them have generally found low rates (2%-5%) of only local, short-term adverse effects.¹⁵ One review article did find that increasing the number of PRP injections increased the rate of adverse effects; however, those effects still appeared to be mild and time-limited.¹⁰

One study reported that 33% (17/51) of patients experienced systemic adverse effects including syncope, dizziness, and nausea at the time of their PRP injection.⁶ Overall, there is no evidence of significant harms associated with PRP treatment, but available studies have lacked the power to detect rare but serious problems.

Looking to the future: Additional considerations

In order to properly evaluate this potentially promising method of care, future studies need to include appropriately chosen controls, specifically defined formulations of PRP, standardized protocols for the injection of PRP, standardized post-injection PT regimens, and patient populations that are clearly defined in terms of severity and chronicity of disease. Furthermore, studies must be rigorously designed in terms of randomization, blinding, and analysis. (Many studies done to date did not use an intention-to-treat protocol, for example). Higher-quality studies with larger numbers of participants are the only way to determine whether PRP is worth all the “buzz.”