thoughts on US guided PRP for chronic tendionopathy

[100YardDash]

Read a study from the journal of injury, function, and rehab.
-retrospective study, total of 180 pts b/w 18-75 yrs old who received US guided PRP inections for tendinopathy refractory to conventional therapy. most common injection sites were medial epicondyle, achilles, patella, rotator cuff, lateral epicondyle, glutes. 60% of pts only received 1 inection. results overall 93% who received injection to the lateral epicondyle, 100% of pts who received achilles, and 59% of pts to the patella reported moderate to complete resolution of symptoms. >80% of pts to the rotator, ham, glute, amd medial epicondyle reported same or greater improvement. f/u time was at 6months and 1 yr. So i know that there are limitatons to this study considering its a retrospective data with recall bias etc. and only 55% of the pts responded to the f/u survey.

thoughts? From recent threads I've read, I got the impression that most think PRP in hocus pocus. Just want to hear from some of the jedi masters on this forum. Appreciate your thoughts

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[oreosandsake]

No Jedi master, but here is a well-designed study.

I think if you want to find data to support intervention X, you will find it. If you want to find data to refute the same intervention X, you can also find it...

JAMA. 2010 Jan 13;303(2):144-9. doi: 10.1001/jama.2009.1986.

Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial.
de Vos RJ, Weir A, van Schie HT, Bierma-Zeinstra SM, Verhaar JA, Weinans H, Tol JL.
SourceDepartment of Orthopedics, Room Ee1614, Erasmus University Medical Center, PO Box 2040, Dr Molenwaterplein 50, 3000 CA Rotterdam, The Netherlands. [email protected]

Abstract
CONTEXT: Tendon disorders comprise 30% to 50% of all activity-related injuries; chronic degenerative tendon disorders (tendinopathy) occur frequently and are difficult to treat. Tendon regeneration might be improved by injecting platelet-rich plasma (PRP), an increasingly used treatment for releasing growth factors into the degenerative tendon.

OBJECTIVE: To examine whether a PRP injection would improve outcome in chronic midportion Achilles tendinopathy.

DESIGN, SETTING, AND PATIENTS: A stratified, block-randomized, double-blind, placebo-controlled trial at a single center (The Hague Medical Center, Leidschendam, The Netherlands) of 54 randomized patients aged 18 to 70 years with chronic tendinopathy 2 to 7 cm above the Achilles tendon insertion. The trial was conducted between August 28, 2008, and January 29, 2009, with follow-up until July 16, 2009.

INTERVENTION: Eccentric exercises (usual care) with either a PRP injection (PRP group) or saline injection (placebo group). Randomization was stratified by activity level.

MAIN OUTCOME MEASURES: The validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire, which evaluated pain score and activity level, was completed at baseline and 6, 12, and 24 weeks. The VISA-A score ranged from 0 to 100, with higher scores corresponding with less pain and increased activity. Treatment group effects were evaluated using general linear models on the basis of intention-to-treat.

RESULTS: After randomization into the PRP group (n = 27) or placebo group (n = 27), there was complete follow-up of all patients. The mean VISA-A score improved significantly after 24 weeks in the PRP group by 21.7 points (95% confidence interval [CI], 13.0-30.5) and in the placebo group by 20.5 points (95% CI, 11.6-29.4). The increase was not significantly different between both groups (adjusted between-group difference from baseline to 24 weeks, -0.9; 95% CI, -12.4 to 10.6). This CI did not include the predefined relevant difference of 12 points in favor of PRP treatment.

CONCLUSION: Among patients with chronic Achilles tendinopathy who were treated with eccentric exercises, a PRP injection compared with a saline injection did not result in greater improvement in pain and activity.

 

[nvrsumr]

no jedi master, but here is a well-designed study.

I think if you want to find data to support intervention x, you will find it. If you want to find data to refute the same intervention x, you can also find it...

Jama. 2010 jan 13;303(2):144-9. Doi: 10.1001/jama.2009.1986.

Platelet-rich plasma injection for chronic achilles tendinopathy: A randomized controlled trial.
De vos rj, weir a, van schie ht, bierma-zeinstra sm, verhaar ja, weinans h, tol jl.
Sourcedepartment of orthopedics, room ee1614, erasmus university medical center, po box 2040, dr molenwaterplein 50, 3000 ca rotterdam, the netherlands. [email protected]

abstract
context: Tendon disorders comprise 30% to 50% of all activity-related injuries; chronic degenerative tendon disorders (tendinopathy) occur frequently and are difficult to treat. Tendon regeneration might be improved by injecting platelet-rich plasma (prp), an increasingly used treatment for releasing growth factors into the degenerative tendon.

Objective: To examine whether a prp injection would improve outcome in chronic midportion achilles tendinopathy.

Design, setting, and patients: A stratified, block-randomized, double-blind, placebo-controlled trial at a single center (the hague medical center, leidschendam, the netherlands) of 54 randomized patients aged 18 to 70 years with chronic tendinopathy 2 to 7 cm above the achilles tendon insertion. The trial was conducted between august 28, 2008, and january 29, 2009, with follow-up until july 16, 2009.

Intervention: Eccentric exercises (usual care) with either a prp injection (prp group) or saline injection (placebo group). Randomization was stratified by activity level.

Main outcome measures: The validated victorian institute of sports assessment-achilles (visa-a) questionnaire, which evaluated pain score and activity level, was completed at baseline and 6, 12, and 24 weeks. The visa-a score ranged from 0 to 100, with higher scores corresponding with less pain and increased activity. Treatment group effects were evaluated using general linear models on the basis of intention-to-treat.

Results: After randomization into the prp group (n = 27) or placebo group (n = 27), there was complete follow-up of all patients. The mean visa-a score improved significantly after 24 weeks in the prp group by 21.7 points (95% confidence interval [ci], 13.0-30.5) and in the placebo group by 20.5 points (95% ci, 11.6-29.4). The increase was not significantly different between both groups (adjusted between-group difference from baseline to 24 weeks, -0.9; 95% ci, -12.4 to 10.6). This ci did not include the predefined relevant difference of 12 points in favor of prp treatment.

Conclusion: Among patients with chronic achilles tendinopathy who were treated with eccentric exercises, a prp injection compared with a saline injection did not result in greater improvement in pain and activity.

1+

 

[spme]

Depends on what kind of tendinopathy you are talking about...

Am J Sports Med. 2011 Jun;39(6):1200-8. doi: 10.1177/0363546510397173. Epub 2011 Mar 21.

Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up.

Gosens T, Peerbooms JC, van Laar W, den Oudsten BL.
Department of Orthopaedic Surgery, St Elisabeth Hospital, Tilburg, the Netherlands. [email protected]

Abstract
BACKGROUND:
Platelet-rich plasma (PRP) has been shown to be a general stimulation for repair and 1-year results showed promising success percentages.

PURPOSE:
This trial was undertaken to determine the effectiveness of PRP compared with corticosteroid injections in patients with chronic lateral epicondylitis with a 2-year follow-up.

STUDY DESIGN:
Randomized controlled trial; Level of evidence, 1.

METHODS:
The trial was conducted in 2 Dutch teaching hospitals. One hundred patients with chronic lateral epicondylitis were randomly assigned to a leukocyte-enriched PRP group (n = 51) or the corticosteroid group (n = 49). Randomization and allocation to the trial group were carried out by a central computer system. Patients received either a corticosteroid injection or an autologous platelet concentrate injection through a peppering needling technique. The primary analysis included visual analog scale (VAS) pain scores and Disabilities of the Arm, Shoulder and Hand (DASH) outcome scores.

RESULTS:
The PRP group was more often successfully treated than the corticosteroid group (P < .0001). Success was defined as a reduction of 25% on VAS or DASH scores without a reintervention after 2 years. When baseline VAS and DASH scores were compared with the scores at 2-year follow-up, both groups significantly improved across time (intention-to-treat principle). However, the DASH scores of the corticosteroid group returned to baseline levels, while those of the PRP group significantly improved (as-treated principle). There were no complications related to the use of PRP.

CONCLUSION:
Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and increases function significantly, exceeding the effect of corticosteroid injection even after a follow-up of 2 years. Future decisions for application of PRP for lateral epicondylitis should be confirmed by further follow-up from this trial and should take into account possible costs and harms as well as benefits.

 

[spme]

Here is another one...

Am J Sports Med. 2013 Jul 3. [Epub ahead of print]

Platelet-Rich Plasma Significantly Improves Clinical Outcomes in Patients With Chronic Tennis Elbow: A Double-Blind, Prospective, Multicenter, Controlled Trial of 230 Patients.

Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S, Vermillion DA, Ramsey ML, Karli DC, Rettig AC.

Department of Orthopedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, Menlo Park, California.

Abstract

BACKGROUND:Elbow tenderness and pain with resisted wrist extension are common manifestations of lateral epicondylar tendinopathy, also known as tennis elbow. Previous studies have suggested platelet-rich plasma (PRP) to be a safe and effective therapy for tennis elbow.

PURPOSE:To evaluate the clinical value of tendon needling with PRP in patients with chronic tennis elbow compared with an active control group. STUDY DESIGN:Randomized controlled trial; Level of evidence, 1.

METHODS:A total of 230 patients with chronic lateral epicondylar tendinopathy were treated at 12 centers over 5 years. All patients had at least 3 months of symptoms and had failed conventional therapy. There were no differences in patients randomized to receive PRP (n = 116) or active controls (n = 114). The PRP was prepared from venous whole blood at the point of care and contained both concentrated platelets and leukocytes. After receiving a local anesthetic, all patients had their extensor tendons needled with or without PRP. Patients and investigators remained blinded to the treatment group throughout the study.

RESULTSatient outcomes were followed for up to 24 weeks. At 12 weeks (n = 192), the PRP-treated patients reported an improvement of 55.1% in their pain scores compared with 47.4% in the active control group (P = .094). At 24 weeks (n = 119), the PRP-treated patients reported an improvement of 71.5% in their pain scores compared with 56.1% in the control group (P = .027). The percentage of patients reporting significant elbow tenderness at 12 weeks was 37.4% in the PRP group versus 48.4% in the control group (P = .036). At 24 weeks, 29.1% of the PRP-treated patients reported significant elbow tenderness versus 54.0% in the control group (P < .001). Success rates for patients with 24 weeks of follow-up were 83.9% in the PRP group compared with 68.3% in the control group (P = .012). No significant complications occurred in either group.

CONCLUSION:Treatment of chronic tennis elbow with leukocyte-enriched PRP is safe and results in clinically meaningful improvements compared with an active control group.

 

[nvrsumr]

70% response from the placebo group? End point of 25% improvement on VAS?

 

[oreosandsake]

I think if you want to find data to support intervention X, you will find it. If you want to find data to refute the same intervention X, you can also find it...

Depends on what kind of tendinopathy you are talking about...

the lateral epicondylitis papers are some of the best to support PRP. But I wonder why should a different tendon make a difference...

also, in regards to the OP question, I was under the impression that US guidance helped you make sure you were in the right place, but did not show improved outcomes

 

[Baritonebass]

Also what kind of prp you use L-prp seems to play nicely with tendons

 

[Gauss]

70% response from the placebo group? End point of 25% improvement on VAS?

active control group
first study to compare tenotomy with or without PRP

 

[Gauss]

the lateral epicondylitis papers are some of the best to support PRP. But I wonder why should a different tendon make a difference...

different histologically, contractile properties, and force loads. patellar and achilles respond differently to tenotomy, scraping, sclerosing, and prp.

joints are not all the same either, so why should tendons be the same?

 

[fozzy40]

different histologically, contractile properties, and force loads. patellar and achilles respond differently to tenotomy, scraping, sclerosing, and prp.

joints are not all the same either, so why should tendons be the same?

Would also add that the design, function, and how we use tendons add to the variability of treatment and subsequently response.

 

[MSKalltheway]

70% response from the placebo group? End point of 25% improvement on VAS?

Based on previous literature of needle tenotomy of the common extensor tendon, I can see why the "placebo" group had this kind of response

 

[spme]

1

 

[spme]

There will be some papers coming out from North East soon comparing tenotomy with or without PRP.

As others said, type of PRP matters (leukocyte rich vs. leukocyte poor), the concentration and ultimately, the amount of growth factors produced matters, and no, not all the tendons are made equal in terms of its constituents and contractile property. As far as sports medicine is concerned, mid-portion partial tear of achilles tendon is different in nature, from insertional partial tear of the same tendon.

TOBI (The Orthobiologic Institute) conference is probably a great place to learn about all these regenerative therapies (pretty pricey, though). I had a wonderful time speaking with giants of MSK medicine from the US and from across the world.

There will be bunch of paper in works now that will come out over next 6 months to 12 months. So stay tuned...

Regenerative therapy = tenotomy, hyperosmoler dextrose injection aka prolotherapy, PRP, stem cell, amniotic membrane, and many more to come.... but we need more people to conduct well designed studies.