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PRP for Lateral Epicondylitis

PRP for Lateral Epicondylitis. Matthew Bloom, OMS IV. Have you had your morning cup of coffee yet?. 300mg/day. Overview. Lateral Epicondylitis Platelet-Rich Plasma Current research on tx of lateral epicondylitis with PRP vs CSI. Lateral Epicondylitis. Also referred to as:

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PRP for Lateral Epicondylitis

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  1. PRP for Lateral Epicondylitis Matthew Bloom, OMS IV

  2. Have you had your morning cup of coffee yet? 300mg/day

  3. Overview Lateral Epicondylitis Platelet-Rich Plasma Current research on tx of lateral epicondylitis with PRP vs CSI

  4. Lateral Epicondylitis • Also referred to as: • Elbow tendinosis • Elbow tendonitis • Elbow tendinopathy • Epicondylalgia • Tennis elbow

  5. Lateral Epicondylitis

  6. Lateral Epicondylitis

  7. Lateral Epicondylitis • Epidemiology • 1–3% in general population • Risk Factors • Smoking • Obesity • Age (45–54) • Repetitive movement (>2 hours daily) • Forceful activity (>20 kg)

  8. Lateral Epicondylitis • Clinical Anatomy • Lateral humeral epicondyle serves as the bony common origin of the wrist extensor muscles • Injury to the extensor carpi radialisbrevis muscle (ECRB) (felt at tip of lateral epicondyle) • Differentiate an effusion in this region, which represents intraarticular pathology or swelling posteriorly due to olecranon bursitis, from the lateral epicondylitis, which is extraarticular in nature

  9. Lateral Epicondylitis

  10. Lateral Epicondylitis • Pathophysiology • Chronic tendinosisrather than an acute inflammatory process • Presence of disorganized tissue and neovasculaturewith very few inflammatory cells • Studies using grayscale ultrasonography and color Doppler followed by anesthetic injection suggest thatvasculoneural growth in the common extensor origin, most commonly the ERCB, is the likely source of pain • Targeting this degenerative tendinosis and neovascularization is the focus of emerging treatments (PRP?)

  11. Lateral Epicondylitis • Mechanism of Injury • Repetitive or explosive athletic movements involving eccentric motion, in which the muscle-tendon unit is lengthened while contracting • Clinical Presentation • Lateral elbow pain with varying severity

  12. Lateral Epicondylitis • Nirschl characterizes seven stages of tendinopathy: • Phase I – Mild pain after exercise activity, resolves within 24 hours • Phase II – Pain after exercise activity, exceeds 48 hours, resolves with warm-up • Phase III – Pain with exercise activity that does not alter activity • Phase IV – Pain with exercise activity that alters activity • Phase V – Pain caused by heavy activities of daily living • Phase VI – Intermittent pain at rest that does not disturb sleep; Pain caused by light activities of daily living • Phase VII – Constant rest pain (dull aching) and pain that disturbs sleep

  13. Lateral Epicondylitis • Clinical Examination • Localized tenderness over the lateral epicondyle and proximal wrist extensor muscle mass • Pain with resisted wrist extension with the elbow in full extension • Pain with passive terminal wrist flexion with the elbow in full extension

  14. Lateral Epicondylitis

  15. Lateral Epicondylitis

  16. Lateral Epicondylitis Cozen’s Test

  17. JAMA Article Review • JAMA February 6, 2013 – Vol. 309, No. 5 • “Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients with Unilateral Lateral Epicondylalgia: A Randomized Controlled Trial” • Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B • Division of Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, Australia

  18. JAMA Article Review • Objective: To investigate the effectiveness of corticosteroid injection, multimodal physiotherapy, or both in patients with unilateral lateral epicondylalgia • Design: A 2 × 2 factorial, randomized, injection-blinded, placebo-controlled trial • Setting: Conducted at a single university research center and 16 primary care settings in Brisbane, Australia

  19. JAMA Article Review • Patients • N = 165 • Enrolled between July 2008 and May 2010 • 1-year follow-up in May 2011 • Age 18 years or older • Eligibility was determined by telephone interview • Physical examination was conducted by one researcher and confirmed by a second

  20. JAMA Article Review • Inclusion Criteria • Unilateral lateral epicondylalgia > 6 weeks • Pain over the lateral epicondyle with pain severity > 30 mm on a 100-mm visual analog scale (VAS) • Pain provoked by at least 2 of the following: • Gripping • Palpation • Resisted wrist or middle finger extension • Stretching of forearm extensor muscles

  21. JAMA Article Review • Exclusion Criteria • Receipt of injection (6 months) • Receipt of a course of physiotherapy (3 months) • Concomitant neck or other arm pain (6 months) • Symptoms suggesting radicular, neurologic, or systemic arthritic conditions • Pregnant or breastfeeding • Contraindication to injection

  22. JAMA Article Review • Randomization • Stratified according to pain severity greater or less than 57.5 mm on a 100-mm VAS • Blinding • Researcher who assessed outcomes was blinded to both injection and physiotherapy assignment • Patients were blinded to injection but not physiotherapy

  23. JAMA Article Review • Interventions • Corticosteroid injection (n = 43) • 10 mg/mL of triamcinolone acetonide in a 1 mL injection plus 1 mL of 1% lignocaine • Placebo injection (n = 41) • 0.5 mL of 0.9% isotonic saline • Corticosteroid injection plus physiotherapy (n = 40) • Placebo injection plus physiotherapy (n = 41)

  24. JAMA Article Review • Interventions • Injections were applied to the site of maximum palpable tenderness at the common extensor origin • Physiotherapy consisted of 8 30-minute sessions over 8 weeks • Patients were advised to avoid any activity that caused or provoked pain and to refrain from strenuous activity for 2 weeks

  25. JAMA Article Review • Interventions • After 2 weeks, a gradual return to normal activity was encouraged to minimize potential for recurrence • Patients were allowed to use an analgesic or anti-inflammatory medication, heat or cold pack, or braces as needed • Patients were discouraged from seeking treatments other than those specifically assigned

  26. JAMA Article Review • Hypotheses • At 1 year, clinical outcomes would be worse in patients receiving CSI vs. placebo • At 1 year, clinical outcomes would be better in patients receiving physiotherapy vs. no physiotherapy • Outcome Measures • Patients estimated their global rating of change at 4, 8, 12, 26, and 52 weeks on a 6-point Likert scale ranging from “complete recovery” to “much worse”

  27. JAMA Article Review • Primary Outcomes • CSI demonstrated lower complete recovery or much improvement at 1 year compared with placebo (83% vs. 96%) • p = .01 • CSI demonstrated greater recurrence at 1 year compared with placebo (54% vs. 12%) • p < .001

  28. JAMA Article Review

  29. JAMA Article Review • Primary Outcomes • No interaction between injection (CSI vs. placebo) and physiotherapy (yes vs. no) (p = .99) • No difference in physiotherapy vs. no physiotherapy at 1 year for complete recovery or much improvement (91% vs. 88%, p = .56) • No difference in physiotherapy vs. no physiotherapy at 1 year for recurrence (29% vs. 38%, p = .25)

  30. JAMA Article Review • Secondary Outcomes • At 4 weeks, significant improvement occurred across the board for CSI compared to placebo injection and physiotherapy (yes vs. no) • At 26 weeks, improvement began to decline for CSI compared to placebo and showed no difference for physiotherapy (yes vs. no) • p < .001

  31. JAMA Article Review • Conclusions • CSI showed improvement at 4 weeks compared to placebo, but a subsequent decline in effectiveness at 6 months, with worse outcome at 1 year • Physiotherapy showed no benefit when combined with CSI at 4 weeks and no long-term benefit overall, however, it was shown to be useful in the short-term when utilized alone • Corticosteroids are potent in suppressing inflammation, but histological evidence does not support an inflammatory response in this condition

  32. JAMA Article Review

  33. Discussion Time! Strengths vs. Weaknesses?

  34. Platelet-Rich Plasma • Overview • PRP is a regenerative therapy useful in addressing many musculoskeletal injuries • PRP is being increasingly used for tx of chronic non-healing tendon injuries • PRP contains growth factors (GFs) that stimulate neovascularization to increase the blood supply and available nutrients for damaged tissue to regenerate • Neovascularization also brings new cells and removes debris from damaged tissue

  35. Platelet-Rich Plasma • Growth factors • Alpha granules are storage units within platelets that contain inactive prepackaged growth factors including: • Transforming Growth Factor Beta (TGFβ) • Vascular Endothelial Growth Factor (VEGF) • Platelet-Derived Growth Factor (PDGF) • Epithelial Growth Factor (EGF) • Fibroblast Growth Factor (FGF) • Together these factors help to stimulate cell replication, angiogenesis, epithelialization, granulation tissue formation, extracellular matrix formation, and regulation of bone cell metabolism

  36. Platelet-Rich Plasma • Production • PRP is a plasma suspension that contains all components of whole blood in varying amounts • Contains at least 200,000 platelets/μL, but generally 3-5× this • Centrifugation of venous whole blood containing an anticoagulant results in a plasma supernatant with a gradient of cellular concentration

  37. Platelet-Rich Plasma • Production • Erythrocytes are the densest and will remain at the bottom • A buffy coat of white blood cells follows • Platelets are at the highest concentration in the plasma layer just above the buffy coat and decrease in concentration toward the top

  38. Platelet-Rich Plasma

  39. Platelet-Rich Plasma

  40. Platelet-Rich Plasma • Pathophysiology • With repetitive overuse, collagen fibers in tendons form micro-tears • Injured tendons heal by scarring, which adversely effects function and increases risk of re-injury • In addition, tendons heal at a slow rate secondary to poor vascularization

  41. Platelet-Rich Plasma • Pathophysiology • Traditional therapies do not alter the tendon’s poor healing capabilities, but rather involve long-term palliative care • Some studies suggest CSIs have adverse side effects including atrophy and worsening structural changes to tendons • However, GFs in platelets are known to promote tissue regeneration…

  42. AJSM Article Review • AJSMJuly 3, 2013 online • “Platelet-Rich Plasma Significantly Improves Clinical Outcomes in Patients With Chronic Tennis Elbow” • Allan K. Mishra, MD, Nebojsa V. Skrepnik, MD, PhD, Scott G. Edwards, MD, Grant L. Jones, MD, Steven Sampson, DO, Doug A. Vermillion, MD, Matthew L. Ramsey, MD, David C. Karli, MD, MBA, Arthur C. Rettig, MD • Allan K. Mishra, MD, Department of Orthopedic Surgery, Menlo Medical Clinic, Stanford University Medical Center

  43. AJSM Article Review • Conflicts of Interest • One or more of the authors has declared the following potential conflict of interest or source of funding: This study was sponsored by Biomet Biologics. A.K.M. receives royalties for patents from Biomet and ThermoGenesis and owns stock in BioParadox and ThermoGenesis. N.V.S. has received payment for speaking and as a consultant from Auxilium and receives research support from Biomet, DePuy, Ferring Pharmaceuticals, Biomemetic, Pfizer, Smith & Nephew, Zimmer, and Wyeth. S.G.E. is a paid consultant and receives research support from Medartis, owns stock or stock options in Mylad, and receives research support from Biomet. G.L.J. is an unpaid consultant for Arthrotek and receives research support from Biomet and Genzyme. S.S. has made presentations for Sonosite. D.A.V. has made presentations for Genzyme and receives research support from Biomet. M.L.R. receives royalties from and is a paid consultant for Integra (Ascension) and Zimmer and has made presentations for Arthrex. D.C.K. is an employee of and receives royalties from Greyledge Technologies. A.C.R. receives research support from Biomet.

  44. AJSM Article Review Objective: To evaluate the clinical value of tendon needling with PRP in patients with chronic tennis elbow compared with an active control group Design: Double-blinded, prospective, multicenter, randomized, controlled trial from 2006 – 2011

  45. AJSM Article Review • Patients • N = 230 • Failed at least 1 conventional therapy • Considerable variability in types and amounts of treatment

  46. AJSM Article Review • Inclusion Criteria • Pain by palpation at the lateral epicondyle • Baseline elbow pain ≥ 50 mm on a 100-mm VAS during resisted wrist extension • H/o elbow pain > 3 months • Pain unresponsive to 1 of 3 conventional tx options: • CSI • PT/OT • NSAIDs

  47. AJSM Article Review • Exclusion Criteria • Pregnancy • Age < 18 years • H/o anemia, bleeding disorder, or blood disorder • H/o CTS on the affected side within 1 year of randomization • Cervical radiculopathy • Systemic disorders such as DM, RA, or hypothyroidism

  48. AJSM Article Review • Exclusion Criteria • Prior surgery for elbow tendinosis • Active elbow tendinosis within 4 weeks of randomization • Low H/H • Abnormal platelet count (outside 150,000 – 400,000) • H/o arthritis or fx of affected elbow • CSI within 6 weeks, PT/OT within 4 weeks, or NSAIDs within 1 week of randomization

  49. AJSM Article Review • Procedure • 2 – 3 mL of PRP injected into the ECRB tendon and surrounding area using a peppering technique • A single penetration into the skin and 5 penetrations of the tendon • Control group was injected with 2 – 3 mL of bupivacaine with same peppering technique • Entire 10-mL syringe was covered in black tape and patients’ arms were draped to maintain blinding

  50. AJSM Article Review

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